Covid Appointment Request Form

Appointment Request - PCR Covid-19 Test

Please complete this form to schedule your Covid-19 test
Thank you for choosing Precision Health Solutions to administer your PCR Covid-19 Testing.

Payment Options:
- Insurance: Accepted for those exposed or symptomatic
- Self Pay:
  - $125 cash or credit card accepted (24-72 hours)
  - $250 cash or credit card accepted (24 hours)
Drive-Up Location - No Appointment Needed:
- 390 Harding Place Suite 102, Nashville, TN 37211
- Open M-F 9-5pm - weekends available upon request
Full Name*

First NameLast Name
Company Name
If applicable
Phone*

Area CodePhone Number
E-mail
Address

Street Address

Street Address Line 2

CityState

Zip Code
Appointment Date:*

MonthDayYear
Appointment Time:*
How many patients need tested?*
If several people are in your testing group at the same testing site, we only need 1 form filled out
Please select box:

STAT (next day results): $25024-72 hour results: $125Symptomatic/Exposed: InsuranceNot sure
Why are you requesting a Covid-19 test?

ExposureSymptomaticWorkSchoolTravelEventSurgeryOther
How did you hear about Precision Health Solutions?*

Friend or Family MemberTN Dept of HealthReferral: PCP or Urgent CareFlyer/PostcardReturning PatientGoogle AdvertisementDo615 WebsiteOther
Any questions or comments?
Please contact us at: (615) 205-6006 or info@precision-healthsolutions.com if you have any additional questions
Status
Collector Name
Collector Status
Date results are required:

MonthDayYear
If applicable
Do you have health insurance?

YesNo
Should be Empty:

Appointment Request - PCR Covid-19 Test

Please contact us at: (615) 205-6006 or info@precision-healthsolutions.com if you have any additional questions