CareCube COVID-19 Patient Information Form

Disclosure Statement

We require you to fill out this form completely for CareCube to provide you with efficient and seamless service. Please fill in this form in CAPITALS for ease of reading. Please do not hesitate to ask our staff for any help in completing this form. Where able please provide your insurance card and valid ID to an CareCube staff member for scanning.Disclaimer: Please note the antigen swab is not a PCR swab. Please liaise with your airline about what specific testing you require to board your flight before testing with CareCube.
Patient Information Form

COVID-19 Antibody/Swab Test
Date *

Month Day Year
Date
Full Name *

First Name Last Name
Gender *
Date of Birth *

Month Day Year
Address *

Street Address

Street Address Line 2

City State

Zip Code
Phone Number *
E-mail *
example@example.com
Confirm E-mail *
example@example.com
Do you have Insurance? *

Yes No
Name of the Insurance *
Insurance Policy Number *
You are here for? *

COVID-19 Rapid Antigen Swab Test COVID-19 Rapid Antibody Test COVID-19 PCR Swab Test Other
Do you have a referral/prescription to take this test? *

Yes No
What is the reason for your testing today? *

Medical Requirement: Symptoms Lasted 5 Days/ Possible Exposure Medical Clearance Travelling Return to School or College Required by Employer Required by Airline Tested Positive for COVID-19 Previously Test Repitition Social Event Community Event Other
How did you hear about us? *

Friends and Families Google Instagram Facebook Email Travel Agency Airlines Doctor Work Existing Patient
Patient Signature (or responsible party if minor) *

Clear
Please verify that you are human *
Should be Empty:

Disclosure Statement

Patient Information Form