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https://s3.us-east-1.amazonaws.com/qbench-prod/analytical-edge/32954/1/26487.pdf?response-content-type=application%2Fpdf&AWSAccessKeyId=ASIA2BEZCKNJXIDB7HYN&Signature=HpOJVZIN7zWssCpXgf5%2F2gzwsK0%3D&x-amz-security-token=IQoJb3JpZ2luX2VjEEYaCXVzLWVhc3QtMSJGMEQCIF8nyp3zVLuylD5SlLN7Kyq6fmwUD71M0EsWYCXJhIQiAiA%2FDa6pKAq5TWiY5pwuugijhLZMKpDFPAFRR2hEdHFCxyrVBAj%2B%2F%2F%2F%2F%2F%2F%2F%2F%2F%2F8BEAAaDDY4OTY2MzI2NzY2NyIMfODeMJxBLFOIH2PeKqkE5qHU%2F8sFhtm2%2Faz80hiCktd0cRSPVd8veFUA7vGgr1nW8qVDnTEsVMkN%2FLjhaKq2NDNHvKzHPCemNkrzN0rU%2BrX6WJByWy49oUhScv2WvS%2FxlOI8wFs1SUcmIaykx7zk%2BB8PVCyqsqPIRSe11mEKunGb1dhvUDiIa3SP1HXgygVMkmAiI0AB0L9cdfiDfAYcFEeJQ3YZmLdW5sErgFgEq2BHhKNU7o4OSDIM0JBMjZTayOb%2B%2FkMxd6mhLQ5qAe%2BeNr62M91BSQJtQc2%2BmtvEdkQRTpQt8pUesHoaW9aAVLNfdIwf3pFG8r5OVgvLzTjKueTVqe%2BzXcO2PQB0uo%2FKaYhPfpPposZnGU1%2B%2FNxzbeZDNbPGfq%2FESNbhRwy7xAU7o9b07nQo7X0IVc%2BGdFKC%2FeJAAE5UNl%2BaZVms5H01%2BVHLIHhLb8QmUdOgS49OV69aac8HQHadHPINTtvO87B1Bef%2FuLi74tdcT%2FwmvAHJ%2FNtxn1%2B9Mnxt1Fb%2BAqUpR0xTYoa%2FlIQht6bdOqCSFVsq%2FAaOBrkO1w0ocJ7wJkl6RfFR%2F9kQjI5rbeaf%2BxPFbepl3W9%2FLYVoIKSacuPnYTrFj8QpTD60k6StJoWGLQs1IIsHB0nGvQg1O90fV3OnmObA9MTU%2FRs5zM59N%2BRVF%2BxlNx2u4KBiYm4R1VX7dogKJv8NUjwyedXPF7tQAtyaTfLOOUBghihxT6zjTXTqGBsndC%2Bs83%2FafzQ8VTDs5v6ZBjqqAZ%2BYsiBy2SscVXUJGe55hmEmbVqf7oZeKYNQruQWO7zxNtVMdLie%2FiwChAk8NAWbfizc%2BGU%2BNuXntr1t5anZWNp8FS8Q6NtHG%2B6anhrT6MAt%2FmhAPA50iVxV8hIxuex2dmnFFIJIKN1WIcP19W0P4v4iXfWiF2swyKHLKPkKTqvafNfo7wk8BlDY9MEd8w8CF%2FpugV6gtd7OthAyimr5xgqg4IzDa31fIQTy&Expires=16651392071
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: