COVID SWAB PATIENT INFORMATION FORM

Are you an established patient of Primary Care of Cape Cod? *

Yes No

If you are an existing patient, please call the office at 508-418-6600 to review your symptoms or exposure, and to schedule the appropriate test.

Do you speak English? VocêFala Inglês? ¿Hablas inglés? *

Yes No

If you do NOT speak English, please designate an English-speaking representative to review the COVID-19 Information Sheet, and to receive your result. ***POR FAVOR, LISTE ALGUÉM (NOME E TELEFONO) QUE FALA INGLÊSPARA RECEBER O SEU RESULTADO E INSTRUÇÕES.******POR FAVOR, LISTE ALGUESM (NOMBRE Y TELÉFONO) QUE HABLA INGLSPARA RECIBIR SU RESULTADO E INSTRUCCIÓN. *** *

Name/NOME/NOMBRE Phone/TELEFONO

Are you over 18 years of age? *

Yes No

At this time, Primary Care of Cape Cod is only testing patients at least 18 years of age. Please contact a local pediatric office for more information.

Have you reviewed the COVID-19 Information Sheet on our website? *

Yes No

Copy the following link into your browser to access the COVID-19 information sheet:

http://primarycareofcapecod.com/dvarnold/COVID%20PATIENT%20INFO%2011.9.20.pdf

Patient Name: *

First Name Last Name

BEST Phone Number: *

Area Code Phone Number

Home Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

E-mail:

Birth Date *

Month Day Year

Sex: *

Male Female

Primary Care Physician:

By signing below, the patient or guardian consents to being tested for COVID-19 using the Sofia SARS Cov-2 FIA test. A positive result indicates the presence of the virus and may result in following strict quarantine procedures. A negative result is reassuring, but we strongly recommend quarantine until reviewing this result with your PCP.* If you have any new symptoms or exposures, please review ASAP with your PCP. Appropriate use of masks, social distancing, and hand washingshould continue no matter the result. All COVID-19 test results are reportable to the MA DPH. The total cost for this test is $100, including the cost of the swab and administrative costs.

*If you do not have a PCP, please contact your insurance company to find doctors accepting patients. Seek urgent medical attention for any severe symptoms such as fever, shortness of breath or chest pain.

Signature *

Clear

Date:

Month Day Year Hour Minutes AM/PM Option

Test must be purchased in advance: Visa, Mastercard, Discover accepted. We have tremendous demand for appointment slots and tests, thus we are not offering refunds if you cancel your test.

COVID-19 Antigen Test $ 100.00

Sofia SARS CoV-2 FIA Antigen FIA. Anticipate same-day results.

Total $ 0.00

Credit Card
First Name	Last Name
Credit Card Number	Security Code
Expiration Month	Expiration Year
Billing Address
Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

COVID SWAB : Patient Information