New testing registration/requisition

COVID testing registration/requisition

Fax results to 435-465-2052 Questions? Call 435-688-3050 Ordering Provider: Kevin Duke, DO - NPI 1003882713
Fax results to 435-465-2052

Questions? Call 435-688-3050

Ordering Provider: Kevin Duke, DO - NPI 1003882713

Your Health Acct# 2116
Name*

First NameLast Name
Address*

Street Address

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CityState / Province

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Phone Number*
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Email*
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Date of Birth*

MonthDayYear
Date
MaleFemale
Hispanic or LatinoNot Hispanic or LatinoOtherUnknown
Alaskan NativeAmerican IndianAsianBlack/African-AmericanNative Hawaiian/Pacific IslanderWhiteUnknown
Rapid COVID-19 Test (15 minutes) $25COVID-19 PCR Test (more official test for flying, etc., will receive a report from the lab within 72 hours to 6 days) Insurance accepted, $25 Co-PaySelf-pay - COVID-19 PCR Rapid 40 minutes $140
InsuranceUninsured
Insurance Company Name
Insurance Policy Number
Insurance Group ID Number
Primary Insured

First NameLast Name
Date test performed

MonthDayYear
Date
Sore Throat - J02.9Cough - R05Vomiting - R11.10Fever - R50.9Loss of taste or smell - R43.2/R43.0Chest Pain - R07.9Shortness of Breath or trouble breathing - R06.02Body Aches - M79.10Fatigue - R53.83Suspected exposure - Z20.828Chills (without fever) - R68.83Other
NoYes
EmailText
Color, Make and Model of Car
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Oxygen Pulse Temperature
Rapid positiveRapid NegativeRapid InconclusivePCR PositivePCR NegativePCR Inconclusive
Patient Notified on Date through EmailCall Text by First Name Last Name.
YesNo
YesNo - PCR
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COVID testing registration/requisition

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