Medicap PCR COVID test

PCR COVID-19 Test Scheduling and Consent Form
Email
example@example.com
Select a 30 minute time slot for your COVID-19 Test Appointment *
Vehicle description
Test will be conducted in vehicle. Please do not enter the pharmacy.
Patient First Name *
Patient Middle Name/Initial
Patient Last Name *
Sex at birth *
Date of Birth *

Month Day Year
Date
Patient Street Address *
Patient City *
Patient State *
You may choose a different option if your State is different
Patient Zip Code *
Patient Phone Number *
Please enter a valid phone number.
Facility Name
Facility Address
Submitted Date

Month Day Year
Date
Facility State
Facility Zip Code
Facility County
Facility Phone
Type of Facility
Ordering Provider Name
Ordering Provider Phone
NPI
Ordering Provider Address
Ordering Provider City
Ordering Provider Zip Code
Is patient pregnant?
Patient Race *
Specify other race
Patient Ethnicity *
Test Name
Specimen Type
Specimen Collected and Tested by
Symptoms (symptoms may occur 2-14 days after exposure to the virus)
If symptomatic when did they first occur?

Month Day Year
Date
Is this your first Covid test?

Yes No
Are you employed in healthcare?

Yes No
Were you hospitalized?

Yes No
Were you in the ICU?

Yes No
Were you a resident in a congregate care setting? (Nursing Home, residential care for people with intellectual and developmental disabilities, psychiatric treatment facilities, group homes, board and care homes, homeless shelter, foster care, or other setting?)

Yes No
Physician Information (Optional)

PCR Covid Test Fee $189.00

PCR Covid Test Fee PCR Covid test fee. This test will not be billed to insurance by Medicap Pharmacy. You can ask for a receipt after the test is performed to bill insurance if you choose. Coverage is not guaranteed. You can pay with cash or check if you don't want to use a credit card. Uncheck this box if you do not want to pay with a credit card.

$ 189.00

Total

$ 0.00

Credit Card

I FULLY UNDERSTAND THAT THIS TEST WILL NOT BE BILLED TO ANY INSURANCE BY MEDICAP PHARMACY. I accept the fee of $189.00 and it is up to my insurance to determine my coverage. In consideration of my participation in this test, I hereby agree to assume all risks. I also understand that results are not designed to replace the care or advice of a medical provider. I understand that if I receive abnormal laboratory test results I should promptly consult with a physician. To agree to participate in this test please sign this form. *

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PCR COVID-19 Test Scheduling and Consent Form

Credit Card