2021 Covid-19 Intake Forms-Fairbanks

Covid-19 Intake Form

600 University Ave, Fairbanks, AK
Regular Office Hours:

Monday through Friday- 8:00 AM- 4:00 PM

Saturday- 9:00 AM- 1:00 PM
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. Our voicemail will be on after hours and on the weekends. We will be right with you when we get your voicemail/text notification!

Due to the short supply of RT-PCR tests, we can only guarantee this test to those who have pre-paid for the test ahead of time. We set aside the test as we receive payment. Thank you for your understanding.
How did you hear about us?
Requested appointment date & time *
Color, make & model of vehicle *
Date *

Month Day Year
Date
Name (How you type it here will auto populate on your Result Report.) *

First Name Last Name
Middle Initial *
If client is a minor please list parent's name below
Date of birth (How you type it here will auto populate on your Result Report.) *

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)-$209 Covid-19 Rapid NAAT (Nasal Swab; 30 minutes)-$275 Covid-19 Rapid RT-PCR (Nasal Swab; within 24 hours) - $275 Covid-19 Lab Based PCR (Saliva, 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 Semi Qualitative Covid-19 Antibody (Blood draw, lab based; results in 2-4 business days after lab receives specimen. Specimens are sent FedEx next day air. Specimens collected on Friday after 10 am or on Saturday will go out the following Monday.) This test is for determining both a positive/negative result with a quantitative measurement of the antibodies present from infection of the live virus. -$149 Immune Response Panel (US Biotek Antibody Test) (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.) This test measures two types of antibodies and is used for determining any naturally occurring COVID-19 antibodies from being infected, as well as the efficacy of inoculation to the virus from the vaccine. -$199 Phlebotomy Fee-$35 Individual Mobile Fee-$50 Group Mobile Fee-$100
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. 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 statements 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. I acknowledge that Lab-based tests can take up to 96 hours and MedPhysicals does not guarantee that the result report will be sent sooner than 96 hours. 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
If traveling, passport number (How you type it here will auto populate on your Result Report. PLEASE DOUBLE CHECK!)
(If traveling) Country of passport origin
(If traveling) Please list country you are traveling to
CONSENT TO RELEASE REUSLT TO EMPLOYER (if applicable)

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

Clear

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

Covid-19 Intake Form

Information about you

Give your consent

Only check if the following statements pertain to your visit today