COVID-19 Patient Screening Disclosure Form

COVID 19 | Patient Registration

For any questions regarding the registration form please contact our Client Services team at: (704) 716-7837
The standard turnaround time is 24-36 hours.

URGENT (STAT) turnaround time is 24 hours, guaranteed.

You may not have out-of-pocket costs if using insurance. You should contact your insurer to confirm coverage before scheduling a test. You may be responsible for the full price of the test ($149.99) if you do not meet the criteria established by your insurer.

Testing is only performed on patients that are 3+ years of age for safety reasons. If patient is younger than 3 years old, please refer to a physician office for testing.

****Please Note: The HRSA Covid-19 Uninsured program for claims submission reimbursement ended 3/22/2022- This means that if you are uninsured you will be responsible for the cost of your covid test in full****

**Our reports DO NOT contain a QR code**
REASON FOR TESTING?

Symptomatic Exposure to COVID-19 Travel Needs Peace of Mind
Patient Demographic Information
Full Name *
Date of Birth *

Month Day Year
Date
Gender *
Ethnicity *
Race *
Mobile Phone # *
Positive result notification: *

In case of a Positive result, I authorize the laboratory to contact me at the number listed above. In case of a Positive result, please contact an alternate number, listed below.
Alternate Phone #
Alternate Phone #
Email Address *
Laboratory result email notification: *

I authorize the laboratory to email a copy of my lab report to the email listed above. I authorize the laboratory to email a copy of my lab report to an alternate email address listed below.
Alternate Email Address
Alternate Email Address
Would you like us to send a copy of your lab results to your primary physician?

Yes No
Primary Physician Name
Office/Facility Name
Office/Facility Fax Number
Patient Address
Patient Address *

Street Address

Street Address Line 2

City State

Zip Code
Appointment Information
Appointment Date *
Vehicle Make and Model *
Vehicle Color *
URGENT?

YES NO
Is COVID screening for TRAVEL purposes? *

Yes No
Patient Required Screening Questions

*Required by the State Health Department.
Do you have symptoms (fever, chills, cough, shortness of breath, etc)? *

Yes No
Have you been exposed to a confirmed case of COVID-19? *

Yes No
When did the symptoms begin?

Month Day Year
Date
Is this your first COVID-19 test? *

Yes No
Are you employed in a healthcare environment with patient exposure? *

Yes No
Have you been hospitalized for COVID-19? *

Yes No
Have you been admitted to an ICU for COVID-19? *

Yes No
Are you pregnant? *

Yes No
Are you a Congregate Care/Nursing Home Resident? *

Yes No
Signature: By signing below, you acknowledge that the answers you provided are true and accurate to the best of your knowledge. (Please use your mouse to sign if you are using a desktop or laptop.) *

Clear
Billing Options *

I have an active insurance Self-Pay (I do not have insurance - HRSA Federal Uninsured Program has ended)
INSURANCE CARD - FRONT
INSURANCE CARD - BACK
Insurance Company Name:
Insurance Policy Number:
Insurance Group Number (if applicable):
DRIVER LICENSE OR VALID STATE ID
DRIVER LICENSE OR VALID STATE ID
ADDITIONAL SERVICES
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SELF-PAY UNINSURED $ 100.00
The HRSA Federal program for the uninsured has stopped accepting claims. The self-pay COVID test is $100. Select this option if you do not have insurance. Uncheck if you have ACTIVE INSURANCE.

OPTIONAL STAT (URGENT) TESTING $ 100.00
24-Hour Turnaround Time Guaranteed. Suitable for Travel Testing Guidelines.Your specimen will be prioritized and completed within 24 hours!

Total $ 0.00

Should be Empty:

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COVID 19 | Patient Registration

Patient Demographic Information

Patient Address

Appointment Information

Patient Required Screening Questions