Full Name*:

Email*:

Cell Phone*:

Address*:

Gender*:

MaleFemale

Date of Birth*:

Picture ID *:

Last 4 digits of Social*:

Do you have Health Insurance?

YesNo

Carrier:

Policy Number:

Insurance Card Photo:

Current Temperature (if possible):

Have you been tested before?

YesNo

Test Results?

Please leave this field empty.

Please enter any symptoms:

Recent Exposure?

YesNoNot Sure

Type of Testing to Perform?

Nasal Swab - SARS-CoV2, RT-PCR This test has been authorized by the FDA under an emergency use authorization (EUA)… $50 processing feeRapid antibodies -Tests for antibodies primarily to check if you have had the virus in the past and current (test results in 15 min). Free for uninsured and insured covered patientsAntigen Testing

Testing Location or Area*:

Expected Date of Visit*:

Parental/Guardian Signature if under 18 years of age (type your name):

Signature (type your name)*:

Signing Date*:

Please carefully read and sign the following Informed Consent:

• a. I authorize this COVID-19 testing unit to conduct collection and testing for COVID-19 through a nasopharyngeal swab or blood draw, as ordered by an authorized medical provider or public health official.

• b. I authorize my test results to be disclosed to the county, state, or to any other governmental entity as may be required by law.

• c. I acknowledge that a positive test result is an indication that I must self-isolate and wear a mask or face covering as directed in an effort to avoid infecting others.

• d. I understand the testing unit is not acting as my medical provider, this testing does not replace treatment by my medical provider, and I assume complete and full responsibility to take appropriate action with regards to my test results. I agree I will seek medical advice, care and treatment from my medical provider if I have questions or concerns, or if my condition worsens.

• e. I understand that, as with any medical test, there is the potential for a false positive or false negative COVID-19 test result.
I, the undersigned, have been informed about the test purpose, procedures, possible benefits and risks, and I have received a copy of this Informed Consent. I have been given the opportunity to ask questions before I sign, and I have been told that I can ask additional questions at any time. I voluntarily agree to this testing for COVID-19.

You agree that you are not obligated to test at our center, and understand that we are a private practice charging separately for testing. Your insurance will pay the labs directly as we collect your insurance information, your payment to us is NOT a co-payment or deductible of any sort.

By Clicking the submit button, I agree to terms and conditions.

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