RAPID COVID TEST PATIENT INFO

PRICE $65.00
Please have payment ready when you get here.
Please call to schedule your testing time.

Hazlehurst, GA (912) 375-2521
McRae, GA (229) 947-4071
Baxley, GA (912) 705-9110
Location.*
Date of Scheduled Apt:*

MonthDay Year
Name*

First Name Last Name
2. Phone #: *
Secondary #:
3. DOB:*

MonthDay Year
Email
example@example.com
Address*

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
5. Reason for testing: *

ExposureSymptoms
6. Symptoms:*

CoughShortness of breathNausea / vomitingDiarrheaLoss of tase / smellFever / chillsHeadacheSore ThroatCongestion / runny noseNone
7. If tested positive, would you like to be treated by our providers?*

YesNo
8. Allergies to medication:*
9. What pharmacy (and location) do you use?*
• This test has not been reviewed by the FDA. The test has been validated but FDA's independent review of the test is pending.
• Negative results do not rule out SARS-CoV-2 infection, particularly in those who have been in contact with the virus. Follow-up testing with a molecular diagnostic should be considered to rule out infection in these individuals.
• Results from antibody testing should not be used as the sole basis to diagnose or exclude SARS-CoV-2 infection or to inform infection status.
• Positive results may be due to past or present infection with non-SARS-CoV-2 coronavirus strains, such as coronavirus HKU1, NL63, OC43, or 229E.
I understand Medical Wellness Centers is offering RAPID COVID TESTING as a SELF PAY service only. Due to the high volume of tests Medical Wellness Centers will NOT be able to file your insurance, under any circumstances. If your test is Positive you will need to see your Primary Care Physician (PCP) for treatment. If you do not have a PCP our Providers will be glad to treat you. Call one of the clinics above for an appointment with our providers. I understand and agree to the above statement; I also consent to pay for this service as a self-pay service only.*

I AGREE
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