Administration Date
Full Name Date of Birth
Race WhiteBlack or African AmericanAsianOther Gender MaleFemaleOther Ethnicity HispanicNon-hispanic Address Are you insured? YesNo Relation to insured? SelfSpouseChildOther Primary Insurance Policy Number
Are you experiencing any of the following symptoms? Sore throat, Cough, Fever, Shortness of breath, Diarrhea, Headache, Body aches, Nausea / Vomiting, Loss of Taste / Smell? YesNo
Has anyone in your household, or any of acquaintances tested positive for COVID-19 within the last 14 days? YesNo
Any recent travels outside of the State or Country? YesNo
Photo of Insurance
Take Photo of ID (Drivers License, Passport, State Issued ID) Type of TestCOVID-19 Rapid Antigen TestCOVID-19 Lab RT-PCRCOVID-19 Molecular PCRFlu/RSV/COVID Combination TestStrep TestCOVID-19 Bivalent Booster Vaccine - ModernaCOVID-19 Bivalent Booster Vaccine - PfizerFlu Shot
I certify that the information provided on this form is accurate. I authorize the place of service to release the results of this test to the ordering provide. I further authorize the lab and the ordering provider to bill my insurance and to receive payment of benefits for the test ordered. I authorize the lab and the ordering provider to release to my insurance provider any medical information necessary to process this claim. I consent and give permission to the provider to contact me to discuss about the test results.
