COVID-19 Testing Patient Inquiry
If you are a patient experiencing symptoms and would like to have a COVID-19 test performed, please fill out the form below. A Vibra Health Lab representative will verify your eligibility, contact your physician for authorization, then call you to schedule your sample collection. Thank you.
Full Name:
*
First Name
Last Name
Date of Birth:
*
-
Month
-
Day
Year
Date
Gender:
*
Male
Female
Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number:
*
-
Area Code
Phone Number
Email (optional):
example@example.com
Primary Insurance:
*
Medicare, Medicaid, Blue Cross, Self-pay/uninsured, etc.
Policy ID Number:
*
Group Number:
if applicable
Check the symptoms that you're currently experiencing:
*
Fever
Cough
Shortness of breath
Fatigue
Sore throat
Runny nose
Sneezing
Headache
Chills
Chest pain
Body aches
Diarrhea
None
Underlying Medical Conditions:
*
Asthma
Diabetes
Lung disease
Heart condition
Kidney disease
Liver disease
Cancer
Hypertension
Obesity
None
Exposure Risk:
*
I have been in close contact with a person known to have COVID-19
I live in or have recently been in an area with ongoing spread of COVID-19
I am 65 years old or older
I live in a nursing home or assisted living facility
I travelled on a plane, train, or bus in the last 14 days
I have been in a group of more than 10 people in the last 14 days
Do you use or do you have history of using tobacco?
*
Yes
No
Primary Care Physician:
*
We will contact them to approve and sign your COVID-19 test order
Primary Care Physician Phone Number:
*
-
Area Code
Phone Number
Primary Care Physician Location:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Submit
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