Rapid Covid Testing Scheduler
Heidi Heras, MD, FFAOA, dipABLM & Becci Johnson, FNP-C
Scheduling
For efficient processing, you must arrive within the first 5 minutes of your scheduled time with a face mask on and your insurance card ready.
Appointment
Which symptoms are you experiencing?
*
Suspected Exposure
Fever or Chills
Cough
Shortness of Breath
Fatigue or Muscle Aches
Headache
Loss of Taste or Smell
Sore Throat
Congestion or Runny Nose
Vomiting or Diarrhea
Skin Rashes
I'm not experiencing symptoms, have no suspected exposure, and understand that insurance is not required to cover the testing without symptoms or exposure.
First Day of Symptoms
-
Month
-
Day
Year
Is this your first covid-19 Test?
*
Yes
No
Are you employed in a healthcare setting?
*
Yes
No
Contact Information
Make sure your information is correct so you can receive your test result promptly.
Patient's Name
*
First Name
Middle Name
Last Name
Patient's Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Email
*
Confirmation Email
example@example.com
Demographic Information
This information is required by the state for reporting purposes.
Date of Birth
*
MM/DD/YYYY
Birth Sex
*
Female
Male
Race
*
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Ethnicity
*
Hispanic or Latino
Not Hispanic or Latino
Billing and Insurance
We accept most insurance. Private health insurers are currently required to cover testing from in-network providers for those with symptoms or suspected exposure. Insurance is not required to cover testing for travel purposes. We also cannot guarantee that airlines will accept your test results. It is your responsibility to verify with your insurance that Dr. Heidi Heras' office is in network.
Primary Insurance
Name of Insurance Plan
*
Insurance ID Number
*
Employer or Group Number
Policy Holder Name
*
Secondary Insurance
You may enter secondary insurance here.
Name of Insurance Plan
Insurance ID Number
Employer or Group Number
Policy Holder Name
Are you the patient or the patient's legal guardian?
*
I am the patient.
I am the patient's legal guardian.
Signature
*
Clear
Date
*
-
Month
-
Day
Year
Submit
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