COVID-19 Testing-PharmRx Pharmacy

Appointment (REQUIRED)

* Please choose a date and time for your appointments *

Patient Information (REQUIRED)

Test will not be performed without ALL required patient information!

Date of Specimen Collection

Date

Time Collected

Legal Name(First) *

(Last) *

(MI)

Patient's Cell Number (REQUIRED) *

Home Phone Number

Patient's Email (REQUIRED) *

example@example.com

Street Address

City

State

Zip

DOB (MM/DD/YYYY) *

Sex *

SSN#

(SSN# required for uninsured patients only)

If the patient is traveling, please fill:

Travel Date

Date

Airline

Vaccination History *

Not Yet Vaccinated Fully Vaccinated

Vaccination completion date

Date

Brand of Vaccine

Employer/School/College Information (REQUIRED)

Contact Number

Not Applicable

Name

Address

Contact Number

Occupation

Race & Ethnicity - Select all that apply (REQUIRED)

American Indian or Alaskan Native Asian Hispanic or Latino Native Hawaiian or Pacific Islander White Not Hispanic or Latino Black or African American Do not wish to disclose:

Insurance Information

Policyholder Name

Insurance Name

Policy #

Group #

Bill Insurance Self Pay Bill Client

CC Report to/ Surgery Center (Optional)

Date of Procedure

Date

Surgery Center Name

Address

City, State Zip

Preoperative COVID-19 screening procedure

Physician Performing Procedure

Patient Signature: I authorize the release of medical information related to services provided herein to my health plan/ insurance carrier and authorize payment directly to QDx Pathology Services and/or lab services provider. I assume responsibility for payment of charges not covered by my healthcare insurer.

Patient Signature

Clear