Respiratory Health Screening

Submission Date*

MonthDayYear
Date
RESPIRATORY HEALTH SCREENING
Let's Check You In
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Email*
example@example.com
Your Weight in Lbs and Height in Feet and Inches*

RECEIVE YOUR TEST
NEW PATIENT - You have NOT been tested by or received a
test kit / sample collection tube from Insyte before.
Are you a NEW PATIENT?*

YesNo

Government-Issued ID
Examples:

State Driver's License
Passport
Military ID
Permanent Resident Card
Tribal Card
Upload the FRONT of Government-Issued ID*
Upload the BACK of Government-Issued ID*
Insurance
Your insurance card MUST have the following:

1.) Insurance Company Name
2.) Your Full Name
3.) Identification Number as a Member / Subscriber / Policyholder

If it does not have any of the following, this may delay the delivery of your tests, and you will be contacted to provide further information
Upload FRONT of Insurance Card (OPTIONAL)
Upload BACK of Insurance Card (OPTIONAL)

NEW PATIENT REGISTRATION
Additional Patient Demographics
Sex Assigned at Birth*

MaleFemale
Mobile Phone*
Please enter a valid phone number.
Address*

Street Address, Unit / Apt / Suite Number

CityState

Zip Code
Do you have a primary care physician?*

YesNo
What is their name?*

First NameLast Name

Medications
Are you taking any medications?*

YesNo

List down your medication(s):*

	Medication	Dose	How often?
1
2
3
4
5
6
7
8
9
10

Do you have trouble keeping up with your medication(s)?*

YesNo

Tobacco Use
Do you currently use or have ever used tobacco products? (including vaping)*

YesNo
Which best describes your status as a smoker?*

Current cigarette smokerFormer cigarette smokerCurrent Other tobacco user (cigars, hookah, chew, vape)Former Other tobacco user (cigars, hookah, chew, vape)
For how many years did you or have you been using tobacco products?*

HIPAA Release
By signing below, I authorize Insyte Biomed, LLC to disclose my complete health record including, but not limited to, diagnoses, lab test results, treatment, and billing records for all conditions, to any individual or organization duly assigned by Insyte Biomed, LLC for my care. My complete health record may be stored and disclosed in electronic copy or access via a web-based portal or by hard copy at my request, at the duration of the past, present, and future periods.

I understand that I am permitted to revoke this authorization to share my health data at any time and can do so by submitting a request in writing to: Insyte Biomed, LLC, 989 W. Kennedy Blvd. Ste 203, Orlando, FL 32810.

I understand that:
- In the event that my information has already been shared by the time my authorization is revoked, it may be too late to cancel permission to share my health data.
- I understand that I do not need to give any further permission for all my protected patient health records and information.
- I understand that the failure to sign/submit this authorization or the cancellation of this authorization will not prevent me from receiving any treatment or benefits I am entitled to receive, provided this information is not required to determine if I am eligible to receive those treatments or benefits or to pay for the services I receive.
Your Full Name*

First NameLast Name
Signature*

Clear

Attestation
By signing below, you agree to all terms and conditions set forth by Insyte Biomed, LLC, particularly but not limited to, the company's policies on HIPAA, the No Surprises Act, Returns and Exchanges, Privacy and Additional Terms of Service

I also agree to subscribe to the communications, educational materials, and other promotions of Insyte Biomed and its affiliates
Signature*

Clear
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