Medicap PCR COVID test

Select a 30 minute time slot for your COVID-19 Test Appointment *

Patient First Name

Patient Middle Name/Initial

Patient Last Name

Date of Birth *

Date

Patient Phone Number *

Please enter a valid phone number.

Email

example@example.com

Vehicle description

Test will be conducted in vehicle. Please do not enter the pharmacy.

Patient Street Address

Patient City

Patient State

You may choose a different option if your State is different

Patient Zip Code

Sex at birth

Patient Race

Specify other race

Patient Ethnicity

Submitted Date

Date

Facility Name

Facility Address

Facility State

Facility Zip Code

Facility County

Facility Phone

Type of Facility

Other facility type specify

Ordering Provider Name

Ordering Provider Phone

NPI

Ordering Provider Address

Ordering Provider City

Ordering Provider Zip Code

Ordering Provider County

Affiliation to Facility *

Is patient pregnant?

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?

Date

Is this your first Covid test?

Yes No

Are you employed in healthcare?

Yes No

Have you been vaccinated for COVID-19?

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 $169.00

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.

$ 169.00

Total

$ 0.00

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

I FULLY UNDERSTAND THAT THIS TEST WILL NOT BE BILLED TO ANY INSURANCE BY MEDICAP PHARMACY. I accept the fee of $169.00 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. *

Clear

Option 1 Option 2 Option 3

PCR COVID-19 Test Scheduling and Consent Form