2021 Covid-19 Intake Forms-Wasilla

Covid-19 Intake Form

4900 E Palmer-Wasilla Hwy, Wasilla, AK
Please TEXT/CALL us when you are parked in our parking lot. This is the only way we will know that you have arrived for your appointment.

Due to the increased number of testing, your wait time may be up to an hour. We will work diligently to make your wait time as short as possible. We thank you for your patience.
Requested appointment date & time *
Color, make & model of vehicle *
Date *

Month Day Year
Date
Name *

First Name Last Name
If client is a minor please list parent's name below
Date of birth *

Month Day Year
Date
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number *
Please enter a valid phone number.
Email *
example@example.com
Race *
Ethnicity *
Gender *
I acknowledge that MedPhysicals Plus, LLC is not a physician's office and DOES NOT bill insurance. I understand that MedPhysicals Plus, LLC provides walk in lab test services and the tests received are by my request. The COVID diagnosis and COVID test CPT codes provided below are available online and is shared by MedPhysicals only as a courtesy. I also recognize that the services provided to me today may or may not be reimbursed by my insurance company. *

Clear
Select services you are requesting *

Covid-19 Rapid Antigen (Nasal Swab) Covid-19 Rapid NAAT (Nasal Swab) Covid-19 Lab Based PCR (Saliva- Lab based, results in 2-4 business days after lab receives the specimen; specimens collected on Friday after 10 am or on Saturday will go out the following Monday.) Covid-19 Antibody (Blood draw, lab based; results in 2-4 business days after lab receives the specimen. Specimens are sent FedEx next day air. Specimens collected on Friday after 10 am or on Saturday will go out the following Monday.) Phlebotomy Fee Individual Mobile Fee Group Mobile Fee
Information about you

Have you had any of the following symptoms in the last 14 days?
Fever- temperature greater than or equal to 100.4 F? *
Persistent dry cough? *
Been in contact with someone who has tested positive for Covid-19? *
Experienced shortness of breath? *
Have you had any other flu like symptoms? *
Are you a woman who is pregnant or nursing? *
Do you have asthma, COPD, emphysema, cancer, diabetes, heart conditions, recurrent pneumonia or are you immunocompromised, other (specify)? *
Other

Give your consent

(Please check every paragraph to confirm consent.)
I consent to testing and laboratory analysis by MedPhysicals Plus, LLC. My results and the information provided by me may be reported to the ordering physician, the person or entity arranging this testing (which may include, without limitation, a current or prospective employer), any of my or their designees, and public health authorities in accordance with applicable law. I consent to receiving email, text messages, and phone calls at the email address and phone number provided by me. My results may be reported to me through any of the foregoing means or any other reasonable mechanism, including web-based applications, at any time as my results are available. Any results I receive are for informational purposes only and do not constitute a medical diagnosis. It is my sole responsibility to seek and obtain medical and other advice relating to this testing and any results I receive. I consent to my information and results being shared with providers of the Physician Services.

I AGREE
I understand that there are possible risks associated with blood draws, saliva and nasopharyngeal swab specimen collection, including, without limitation, infection, discomfort, and bruising. I understand these risks may not be all-inclusive and that other more remote risks may be involved. As with all laboratory tests, there is a chance of a false positive or false negative result. By initialing, I am agreeing to all of the terms of this Notice, Consent, and Release for COVID-19 Testing. To the fullest extent permitted by law, I release and forever discharge MedPhysicals Plus, LLC and the laboratories they employ to perform the testing and analysis and the person or entity arranging this testing from liability relating to the Physician Services and the collection, testing, and reporting of information described herein.

I AGREE
MedPhysicals Plus, LLC requires payment at the time of service and by signing below I agree that I am financially responsible for all services I may acquire from my visit(s). I acknowledge that MedPhysicals Plus does not bill any health insurances. I understand that a detected/positive test DOES NOT mean that I am immune to COVID-19 and that I will never catch the virus again. In consideration for such services being rendered on my behalf, I hereby RELEASE MPP, its officers, agents, and employees, from any and all claims which I might otherwise have due to such results being made so available. I hereby CONSENT NOT TO FILE ANY ACTION at law or in equity against company connection with the results of such screen being made so available, and I herby agree to INDEMNIFY and SAVE HARMLESS MedPhysicals Plus, LLC, the laboratory testing service, their respective officers, agents, and employees from all damages, expenses, reasonable attorney's fees, and costs of court which they or any of them may suffer or incur, jointly or severally, due to the results of such screen being made so available. *

I AGREE
I am at least of 18 years of age or the legal guardian of the donor with authority to consent on their behalf. I AGREE TO ALL OF THE TERMS OF THIS NOTICE, CONSENT AND RELEASE FOR COVID-19 TESTING.

I AGREE
Only check if the following symptoms pertain to your visit today
TESTING FOR TRAVEL PURPOSES: I understand that it is my sole responsibility, as the traveler and client, to research which COVID-19 test is required for where I am traveling to. I understand that MedPhysicals Plus, LLC will conduct the COVID-19 testing that I request. By signing below, I release the right to a refund if I, the client, order the wrong test or have the test completed outside of the required time limit for the places I am traveling to.

I AGREE
CONSENT TO RELEASE REUSLT TO EMPLOYER

I AGREE
I give consent for my result to be released to
Signature *

Clear

How are you paying for today's test?

Credit/ Debit Card Cash Employer/ Third Party
If we are billing an employer/ third party, please provide name of company/ person and their contact information (phone number). By providing the information below, you authorize MedPhysicals Plus to release the test result to this person(s).
Please only select a service item from below if YOU are responsible for your payment.

DO NOT select any services below if your Employer is paying for the service today. You will be required to enter a credit card if you make a service selection below.
Please list last four of card below

My Products

Rapid Antigen Test (Nasal swab, results in 30 minutes)

$ 209.00

Rapid NAA Test (Nasal swab, results in 30 minutes)

$ 290.00

Saliva PCR Test (Lab based; results in 2-4 business days after lab receives the specimen. Specimens are sent FedEx next day air. Specimens collected on Friday after 10 am or on Saturday will go out the following Monday.)

$ 199.00

Antibody Test (Lab based; results in 2-4 business days after lab receives the specimen. Specimens are sent FedEx next day air. Specimens collected on Friday after 10 am or on Saturday will go out the following Monday.)

$ 149.00

Individual Mobile Fee

$ 50.00

Group Mobile Fee

$ 100.00

Total

$ 0.00

Credit Card
First Name	Last Name
Credit Card Number	Security Code
Expiration Date	Postal Code

You will receive a confirmation email with a receipt and a copy of the form you filled out. A seperate email is generated with a password to open the form. Thank you and take care!
Should be Empty:

Covid-19 Intake Form

Information about you

Give your consent

Only check if the following symptoms pertain to your visit today