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Appointment Details
Phone Number:
Appointment date:
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 :
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? :
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: