• COVID-19 Testing

    RT-PCR (Nasal swab)
  • Appointment (REQUIRED)

  • Patient Information (REQUIRED)

    Test will not be performed without ALL required patient information!

  •  /  /
    Pick a Date
  • If the patient is traveling, please fill:

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    Pick a Date
  •  /  /
    Pick a Date
  • Employer/School/College Information (REQUIRED)

  • Race & Ethnicity - Select all that apply (REQUIRED)

  • Insurance Information

  • CC Report to/ Surgery Center  (Optional)

  •  /  /
    Pick a Date
  • 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.

  • Clear
  •  
  • Should be Empty:
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