• RAPID ANTIGEN & RT-PCR TESTS FORM WITH INSURANCE (US ONLY)

    International insurance is not accepted, if uploaded their appointments will be cancelled without any notice
    • Negative Results of antigen are confirmed with gold standard tests which is RT-PCR
    • Medical Necessity Covid Tests are covered with valid insurance
  • Testing Date
     - -

  • Contact Information

  • Reason for COVID test?*

  • RAPID ANTIGEN TEST

     

  • RT-PCR TEST

  • Please upload JPG or PNG image files.

  • ANTIGEN & PCR TEST FORM

    (TO CONFIRM NEGATIVE ANTIGEN TEST RESULTS WE PERFORM GOLD STANDARD TEST WHICH IS PCR AS WELL)

  • Appointment Schedule

  • FAMILY MEMBERS WITH DIFFERENT TIMES CAN VISIT FOR APPOINTMENTS AT THE SAME TIME

    WALKINS ARE WELCOME !!!!

  • Appointment*

  • Patient Demographic Information

  • Gender*
  • Date of Birth*
     - -
  • Format: (000) 000-0000.

  • Additional Family Members

    Family members with same insurance can continue adding their family, if they have different insurance please fill out separate application and upload proper insurance

  • Patient Health Information

  • Date exposed to COVID 19 (if known)?
     / /
  • Format: (000) 000-0000.

  • Which of these symptoms do you currently have?

  • Do you have any of the following medical conditions?
  • Have you taken any medications for these symptoms?*
  • Fever?*
  • Cough?*
  • Vomiting?*
  • Diarrhea?*
  • Shortness of Breath?*
  • Chills?*
  • Sore Throat?*
  • Muscle Pain?*
  • New loss of Taste or Smell?*
  • Have you been prioritized by your local health department for testing?*
  • Are you a health care worker, first responder, or law enforcement officer?*
  • Do you live or work in a treatment facility, group home, or other group setting?*
  • Are you a caregiver for an elderly person or someone with a weakened immune system?*
  • Have you been tested for COVID-19

  • Acknowledgment and Consent

    I acknowledge that all information I entered in this form is accurate and true. I authorize this facility to collect a sample specimen for me in order to perform this test. I release the facility and all of its employees and affiliates, from any liabilities, damage, or accidents related to this testing activity. I authorize this facility to share with the requester (e.g company) my health care information including diagnostic test results and medical test results. I understand that this diagnostic test is for informational purposes only. This facility will not admit patients or provide medical advice.

  • HIPAA

    I understand that, under the Health Information Portability and Accountability Act of 1996 (HIPAA), I have certain rights to privacy regarding my Protected Health Information.

    By signing below, I understand that the information can and will be used to:

    • Conduct, plan and direct my treatment and follow-up among the multiple healthcare providers who may be involved in that treatment directly and indirectly.
    • Obtain payment from third party payers.
    • Conduct normal healthcare operations such as quality assessments and physicians certifications.

    I understand that I may request in writing that you restrict how my information is used or disclosed to carry out treatment, payment of healthcare operations. I also understand that you are required to agree to my requested restrictions, and if agreed, they you are bound to abide by such restrictions. I understand that I may revoke this consent in writing at any time, except to the extent that you have taken action relying on this consent.

  • Date Signed*
     - -
  • TESTING DATE
     - -
  •  
  • Should be Empty: