Respiratory Health Screening
  • Image field 749
  • Image field 359
  • Submission Date*
     - -

  • RESPIRATORY HEALTH SCREENING

  • Let's Check You In

  • Date of Birth*
     - -

  • Respiratory Health

    Covid-19, Flu A/B, Strep-A
  • Are you experiencing any of these symptoms?*
  • Additionally, are you experiencing any of the following*
  • Have you been in contact with someone who has tested positive for COVID-19, has COVID-19 or is being evaluated for COVID-19?*
  • Have you tested positive for Covid-19 in the past 10 days?*
  • Are you currently awaiting results from a COVID-19 test?*
  • Have you been diagnosed with COVID-19 by a licensed physician in the last 10 days?*
  • Do you currently reside or work in the United States of America?*
  • Have you traveled internationally for the past 14 days?*

  • 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?*

  • Government-Issued ID

  • Image field 726

  • Examples:

    State Driver's License
    Passport
    Military ID
    Permanent Resident Card
    Tribal Card

  • Insurance

  • Image field 732

  • 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

  • NEW PATIENT REGISTRATION

  • Additional Patient Demographics

  • Sex Assigned at Birth*
  • Format: (000) 000-0000.
  • Do you have a primary care physician?*

  • Medical History

  • Do you have any of the following conditions? (Select all that apply):*
  • Do you have any allergies?*

  • Medications

  • Are you taking any medications?*
  • Rows
  • Do you have trouble keeping up with your medication(s)?*

  • Vaccination History

  • Rows

  • Tobacco Use

  • Do you currently use or have ever used tobacco products? (including vaping)*
  • Which best describes your status as a smoker?*

  • 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.

  • 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

  • Should be Empty: