Covid-19 Test Registration (Southern California) by Second Bio Lab SBL

Full Name*

First NameLast Name

Sex*

MaleFemaleOther

Date of Birth

Date

Address*

Street Address

Street Address Line 2

CityState

Zip Code

Phone Number*

Please enter a valid phone number.

Email*

Please enter a valid email. IMPORTANT: This email will receive your Patient ID number as well as details for testing/vaccination.

Race*

This information will be used by the state of California for future services.

Ethnicity*

This information will be used by the state of California for future services.

have you ever had vaccination?

Date of the last vaccine

Date

Please choose what type of service you need

Vaccination ONLYCOVID-19 test ONLYBoth Vaccine and COVID-19 TestAll of above

The type of vaccine you desire, initial dose, second dose or booster

Please select an option

Insurance Information*

Insurance Name

Insurance Group Number

Insurance ID NumberInsurance Group Number

Take Photo of your insurance card (front)*

2) OR upload a photo of your insurance card*

Driver's License number*

Take Photo of Driver's License*

To Pacific Horizon Medical Center (Dr. Zhi Zeng MD Ph.D.):

I consent to use the above-submitted information to register, and I understand the form submission is HIPAA protected.

I understand that the vaccination schedule depends on the availability and national priority. I also understand that this online registration is for the purpose of organizing contactless vaccination. Furthermore, the registration is not a guarantee for vaccination on my own schedule, and I can choose any other physician to get vaccination after this registration. The clinic will contact me for the time and date of vaccination scheduling and may need to make telehealth and/or require an in-person visit.

I understand that vaccination is an ongoing process, and many types of vaccines are in the making and waiting for FDA Emergency Use Authorization. I acknowledge that the presented vaccine may vary in its properties, such as duration of protection from infection, percentage of effectiveness or efficacy, or even unknown long-term side effects.

The information provided above is true to the best of my knowledge. I agree to pay for COVID-19 services through one of the following: (1) I authorize Pacific Horizon Medical Center to bill my insurance for the services provided. (2) I don’t have medical insurance, and cannot afford to pay. The clinic will bill the government COVID-19 program for the services provided to me (including vaccination and/or telemedicine or per office visit). (3) I choose to pay by cash.

I also understand that due to each insurance's regulations and limitations, the clinic may not be able to take certain insurances. Therefore, I understand that the clinic reserves its choice to schedule only patients contracted insurance. In such cases, I understand that I am recommended to find another service.

By checking the box below and adding my signature, I guarantee that I have read and accepted the above information.

Signature*

Patient ID

Covid-19 Test Registration (Southern California) by Second Bio Lab SBL

General Information

Insurance Information

Insurance Card Photo

Terms and Conditions

Patient ID and QR Code