Medicap PCR COVID test

PCR COVID-19 Test Scheduling and Consent Form
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 *

Month Day Year
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

Month Day Year
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?

Month Day Year
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

RT-PCR-NAAT MESA BIOTECH SARS-COV-2 (COVID-19) RT-PCR-NAAT

$ 169.00

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 $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. *

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PCR COVID-19 Test Scheduling and Consent Form

Credit Card