COVID-19 Test
Patient Information
Name
*
First Name
Last Name
Email
*
Cell Phone
*
Date of Birth
*
-
Month
-
Day
Year
Gender
*
Female
Male
Race Ethnicity
*
African American
Asian
Caucasian
Hispanic
Native American
Other
Shipping Address
*
Street Address
Street Address Line 2
City
State
Zip Code
Billing Address
*
Street Address
Street Address Line 2
City
State
Zip Code
Clinical Information
First Test
*
Yes
No
Employed in Healthcare?
*
Yes
No
In nursing home or assisted living?
*
Yes
No
Pregnant?
*
Yes
No
Symptomatic as defined by CDC?
*
Yes
No
Symptoms may include: Fever or chills, Cough, Shortness of breath or difficulty breathing, Fatigue, Muscle or body aches, Headache, New loss of taste or smell, Sore throat, Congestion or runny nose, Nausea or vomiting, Diarrhea
Date of symptom onset
*
-
Month
-
Day
Year
Date
Patient Declaration
Review the information entered above to ensure it is correct and make any necessary edits.
Patient Information
*
I confirm that the information provided in this form is accurate.
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COVID-19 Test
Patient Organization
Affiliated Organization
*
Integrative Emergency Services
Team Rubicon
No Affiliation
Patient Consent
Consent for Lab Testing and Communication of Results:
*
Authorization for Release of Information to Team Rubicon
*
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COVID-19 Test
Billing
COVID-19 Test Fee
*
$50.00
COVID-19 Test Fee
*
$0.00
COVID-19 Test Fee
*
$59.00
COVID-19 Lab Fees
*
Lab Services (Cash Pay)
Bill my Insurance
COVID-19 Lab Fees
*
Lab Services (Cash Pay)
Bill my Insurance
Preferred Shipping Method
*
2 Business Days - Free
Expedited Overnight Delivery by 3pm
I already have a test
Front of Insurance Card
*
Upload Image
Cancel
of
Back of Insurance Card
*
Upload Image
Cancel
of
Payment Summary
IES Affiliate COVID-19 Test Fee
$50.00
COVID-19 Lab Services
{covid19Lab}
Preferred Shipping Method
{preferredShipping}
*FSA & HSA cards accepted.
Team Rubicon COVID-19 Test Fee
$0.00
COVID-19 Lab Services
$0.00
Preferred Shipping Method
{preferredShipping}
*FSA & HSA cards accepted.
COVID-19 Test Fee
{covid19Test150}
COVID-19 Lab Services
{covid19Lab}
Preferred Shipping Method
{preferredShipping}
*FSA & HSA cards accepted.
Financial Consent
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COVID-19 Test
Checkout
Please review the following details for this transaction.
Payment Summary
COVID-19 Test Fee
$50.00
COVID-19 Lab Services
{covid19Lab}
Preferred Shipping Method
{preferredShipping}
*FSA & HSA cards accepted.
Payment Summary
COVID-19 Test Fee
$0.00
COVID-19 Lab Services
$0.00
Preferred Shipping Method
{preferredShipping}
*FSA & HSA cards accepted.
Payment Summary
COVID-19 Test Fee
{covid19Test150}
COVID-19 Lab Services
{covid19Lab}
Preferred Shipping Method
{preferredShipping}
*FSA & HSA cards accepted.
Total Amount Due
Total Amount Due
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