XYZ COVID-19 Order Form

XYZ COVID-19 Order Form
FOR THE SAKE OF SCIENTIFIC ACCURACY, WE RECOMMEND PCR TESTING WHEN TRAVELING, DETERMING ACTIVE CORONAVIRUS INFECTION, AND RULING OUT SYMPTOMS.
Select your COVID-19 Test (SELECT ONE)*

PCR TestRapid TestBOTH PCR & Rapid Tests
Patient Name*

First NameLast Name
Patient Date of Birth*
Patient Address*

Street Address

Street Address Line 2

CityState

ZipCountry
County
Ex; Colllin, Tarant, Ellis, Dallas, Rockwall, Harris, Etc... (NOT COUNTRY)
Email Address for Results Transmission*
example@example.com
Gender*

MaleFemale
Patient Phone #*
Patient Ethnicity*

American Indian or Native AmericanAsianBlack or African AmericanNative Hawaiian or Pacific IslanderWhiteOther
Patient Race*

HispanicNon-HispanicOther
Please select all that apply for the patient*

I have traveled outside of the United States within the past 14 daysI don't have symptoms, but I believe that in the past 14 days I have come into contact with someone that has COVID-19Within the past 14 days, I have come into contact with someone that has tested positive for COVID-19Within the past 14 days, or currently, I have had a fever of 100.4F or greaterWithin the past 14 days, or currently, I have had a coughWithin the past 14 days, or currently, I have experience(d) shortness of breathWithin the past 14 days, or currently, I have had difficulty breathingWithin the past 14 days, or currently, I have experienced loss of taste or smell
Payment Options*

Insurance (If you have insurance, please do not select the CARES act)CARES Act (For uninsured individuals with symptoms, exposure, or possible exposure)
Name of your insurance Company
Insurance ID #
Insurance Group #
Image of insurance card

Cancelof
Social Security #
Image of Government issued ID card

Cancelof
I HAVE READ AND ‎UNDERSTAND THIS CONSENT FORM AND HAVE ASSUMED ALL RISK INVOLVED IN PARTICIPATING IN THIS ‎TESTING. I RELEASE AND HOLD HARMLESS ELITEMED AND ANY AUTHORIZING PHYSICIAN, INCLUDING THEIR ‎EMPLOYEES, AGENTS AND CONTRACTORS, FROM ANY LIABILITY, CLAIM, INJURY, DAMAGES, ATTORNEYS’ ‎FEES ORHARM OF ANY NATURE THAT MIGHT RESULT FROM THE TESTING, INCLUDING THOSE INVOLVING ‎MY PHYSICAL OR MENTAL HEALTH, MEDICAL TESTING PROCEDURES, ERRORS IN TEST RESULTS, OR THE ‎RELEASE OR USE OF INFORMATION RELATING TO THE TESTING, AS LONG SUCH RELEASE OR USE OF ‎INFORMATION IS WITH IN THE SCOPE OF THIS CONSENT. IN ADDITION, I HEREBY CERTIFY THAT ALL INFORMATION LISTED ON THIS FORM IS TRUE.*

Yes
Patient Signature*

Clear
Relationship to Patient
Should be Empty: