Appointment Details

Name:

Email:

Phone Number:

Appointment date:

Location:

Service:

Gender:

I am making this appointment for::

Your Name::

Relationship to Patient::

Employer (or N/A for not appliable):

Most COVID-19 testing is 100% covered by insurers. Do you have your insurance card available?:

Current Insurer:

Other Provider:

Name of referring physician (Medicaid/SoonerCare requires a physician referral):

Insurance Member Name:

Insurance Health Plan:

Insurance Member ID:

Insurance Group ID:

Insurance Payor ID:

Insurance Claims Address:
Name :

Street:

City:

State:

Zip:

I will pay for services by cash or credit card onsite before testing services are provided.:

Do you have your drivers license, government-issued picture ID, or passport available?:

Before services are rendered, a valid, government-issued photo ID or valid passport must be presented:

Are any of the selected symptoms related to, a residual of, or a result of previous COVID 19 infection?:

Month/Year of initial date of positive?:

Are you currently experiencing any of the following symptoms::

Other symptoms:

Are you pregnant? :

Trimester:

Have you traveled out of country/state within last 35 days? :

Countries/States Travelled To::

Have you had a COVID-19 PCR (nasal swab) test?:

Was the nasal swab test::

Is this a follow-up after Covid-19 has been resolved?:

Is your test being done to confirm a previous test? :

Month/Year of Previous Test:

Have you been possibly, suspected or actually exposed to someone who has been confirmed to be positive for COVID-19 within the last last 14 days?:

Were you exposed by:

HIPAA Release and Consent Form: