NEW Orlando Office Appointments

FG Health

3295 Oxford Drive

Kissimmee, Florida 34746

Phone: (689) 888-0456

How did you hear about us? *

Friend/Family Google Physician

Date

First Name *

Last Name *

Full Name

Gender *

Male Female No Response

Date of Birth (MM/DD/YYYY) *

Date

Age

Phone *

Area Code Phone Number

E-mail *

Confirmation Email

Street Address *

City *

State *

Zip *

County *

Lake Orange Osceola Polk Seminole Volusia

Is this your home address *

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Street Address 2 *

City 2 *

State / Province

Zip 2 *

Country *

Home Address

Passport Number

Appointment *

Selected Appointment

Please carefully read the following prior to booking your appointment.

1. I authorize this COVID-19 testing laboratory to conduct collection and testing for COVID-19 through a swab or blood draw.

2. I authorize my test results to be disclosed to the county, state, or to any other governmental entity as may be required by law.

3. I acknowledge that a positive test result is an indication that I must self-isolate and/or wear a mask or face covering as directed in an effort to avoid infecting others.

4. I understand the testing unit is not acting as my medical provider, this testing does not replace treatment by my medical provider, and I assume complete and full responsibility to take appropriate action with regards to my test results. I agree I will seek medical advice, care and treatment from my medical provider if I have questions or concerns, or if my condition worsens.

5. I understand that, as with any medical test, there is the potential for a false positive or false negative COVID-19 test results. I understand and agree that all charges are refundable up to 24 hours before my appointment. Charges are non refundable within 24 hours of my appointment. No shows will be charged the full amount. This is a cash service. We do not accept any insurance. We do not accept Medicaid or Medicare payment for this service. We do not offer COVID medical or travel guidance. For medical questions: FDOH Covid DOH Hotline: 1.866.779.6121 For travel requirement and policies please contact your airline.

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Signature

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Available Services *

PCR VIP (60-90 min Results) $400.00 RT PCR (Results in 3 hours) $200.00 Biofire PCR + Respiratory panel (COVID PCR, Bacterial + viral panel) $450.00 Rapid Antibody test (IGM, IGG) $95.00 Rapid Antigen test (results within 30 minutes) $120 PCR + Flu $275

Available Services (hidden w/ prices)

PCR VIP (60-90 min Results) RT PCR (Results in 3 hours) Biofire PCR + Respiratory panel (COVID PCR, Bacterial + viral panel) Rapid Antibody test (IGM, IGG) RT-PCR & IGM/IGG Antibody (results in 4 hours) Rapid Antigen test (results within 30 minutes) Rapid Antigen + Flu test combination PCR + Flu

Calculation

Total

USD Description

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Test Type *

Test Type DOH *

Collection Date *

Date

Collection Time *

: Hour Minutes AM/PM Option

Collection Date&Time *

Collected Specimen Type *

PCR Results *

Antigen Results *

Antibody Results IGG *

Antibody Results IGM *

Overall Test Results *

Flu A Results *

Flu B Results *

Ethnicity

Sticker Info:

{fullName} {gender} {dateOf27} {age}

{streetAddress} {city} {state} {zip}

{phone}

{email8}

{passportNumber}

{date} {testType}

FG Health Scheduling and Payments

Florida Address

Home Address