PCR Test Application- E-SOL

PCR Test Application

E-Sol
First Name*
Last Name*
Email*
example@example.com
Verify Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Address*
Apartment/Suite/Space #
City*
State*
Zip Code*
Date of Birth*

MonthDayYear
Gender*
ID or Driver's License #*
Ethnicity*
Race*
Upload a copy of your valid state ID *

If you are insured your Valid ID can be a Drivers License, Passport or any other Government ID and can be from any State. If you are uninsured your Valid ID must be from the state of California. If you are the parent or guardian for a minor being tested please upload your Valid ID.
Cancelof
Do you have health insurance?*

YesNo
Insurance Company Name
Policy Number
Group Number
Subscriber Name
Relationship to Insurance Holder
Upload a copy of your health insurance

Cancelof
No Insurance Waiver
By choosing the uninsured option, I hereby, acknowledge under penalty of law that I do not have insurance. I knowingly and voluntarily enter into this WAIVER AND RELEASE OFLIABILITY and hereby waive all rights, claims or causes of action of any kind arising out of my providing misinformation.
This WAIVER AND RELEASE OF LIABILITY shall remain in effect for the duration of my
participation in the activity, during this initial and all subsequent events of participation.
No insurance waiver signature

Clear
Insurance Waiver Date

MonthDayYear
Date
PATIENT CONSENT FOR COVID-19 TESTING

I, the patient, voluntarily consent to the collection and testing of my specimen. I certify that the specimen is fresh and has not been adulterated in any manner. I authorize the laboratory to release the results of this testing to the ordering provider or authorized screening entity.

I understand that the novel Coronavirus (COVID-19) has been declared a global pandemic by the World Health Organization (WHO). I further understand that COVID-19 is extremely contagious and may be contracted from various sources. I understand COVID-19 has a long incubation period during which carriers of the virus may not show symptoms and still be contagious. If presenting symptoms, I also consent to the testing of my specimen for other upper respiratory conditions that may not be detected by a COVID-19 test alone.

I further authorize my insurance benefits to be paid directly to Ananda Analytical Laboratories for services rendered. I acknowledge that the lab may be treated as an out of network provider. In the event I receive payment for laboratory services from my insurer, I will remit said payment to the lab within 14 days of receipt. All rights to the samples will belong to the laboratory conducting the testing.

Your signature on this form indicates that you understand to your satisfaction the information about the test and agree to have the test done.
Consent Name

First NameLast Name
I agree and consent to these terms.*

Yes, I agree and consent to these terms.
Consent for Minors Undergoing COVID-19 Testing

As the parent or guardian of the minor named herein, I authorize Ananda Labs to collect and test a nasal or mouth specimen from said minor and hereby consent to the terms and conditions of this document.
Consent for for Minors

I have read and agree to the Consent for for Minors
Consent Agreement Signature*

Clear
Consent Agreement Signature Date*

MonthDayYear
Date
Please list any symptoms you may have:*

Suspected Exposure - Z20.822Known Exposure - Z20.822Cough - R05.9Fever - R50.9Sore Throat - R07.0Congestion/Runny Nose - R09.81Diarrhea - R19.7No Symptoms Z11.59
Would you like to take a Covid PCR + Flu Test based on your symptoms?

YesNo
By submitting this form I give consent to Esol to view my results.

I consent
Saed Sadeghi, MD
Electronically Signed

{dateCollected}
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