City of Knowledge

City of Knowledge
Please Be Sure To Complete All The Sections.

The test will be billed to your medical insurance, Medi-Cal, or HRSA if uninsured.
Is the person being tested over the age of 18? *
Person Being Tested *

First Name Last Name
Date of Birth *
00/00/0000
Parent/Guardian *

First Name Last Name
Parent/Guardian Date of Birth *
00/00/0000
Phone Number *

Area Code Phone Number
Email Where The Results Should Be Sent To *
example@example.com
Birth Sex *
Address MUST Match The Address On File With Your Insurance Company *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Photo ID: Drivers Licease, State ID, Passport *

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If underage, please upload parents ID Cancel of
Do You Have Health Insurance? *
Medical Insurance Name *
(Anthem, Blue Shield, Kaiser, HealthNet, Etc.)
Medical Insurance Number *
Medical Group Name (This Is Needed IF You Have An HMO Plan IF You Have A PPO Plan Then Type NONE) *
(Monarch, Prospect, IHP, Optum)
Medical Group Number (This Is Needed IF You Have An HMO Plan IF You Have A PPO Plan Then Type NONE) *
(IF NO GROUP NUMBER, Type NONE)
Insurance Card: Front Side *

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Front Side Cancel of
Insurance Card: Back Side *

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Back Side Cancel of
Permission To Test for Covid
Ethnicity *
School Name *
Requester Authorization:

I give my permission for my child and/or myself to be tested for COVID-19.
Name *

First Name Last Name
Today's Date: *
Signature *

Clear
COVID History Form

The following questions is for the individual thats getting tested.
I am: *

Current Symptoms *

	YES	NO
CURRENTLY has fever/chills
CURRENTLY have shortness of breath (IF YES PLEASE CALL 911 OR GO TO ER)
CURRENTLY has cough
CURRENTLY has chest pain (IF YES PLEASE CALL 911 OR GO TO ER)
New onset loss of taste or smell
Body Aches
Nasal congestion, sore throat, runny nose

Other Current Symptoms: *
If none type NONE

Active Medical Conditions *

	YES	NO
Asthma/COPD
Diabetes
Cancer
Autoimmune Disease
Heart Disease

Other Chronic Medical Conditions: *
If none type NONE
Do You Take Medications Daily? *
List all the medications you are currently taking: *
Are you allergic to any medications? *
List the medications you are allergic to: *
I live with: *
Other *
By placing my signature below, I hereby certify that the information above is true and correct. *

Clear
Results Follow Up

Primex Labs will send a text notifying how to log in and get your results.

If you have questions, contact results@xurgentcare.com
Should be Empty:

	YES	NO
I smoke cigarettes
I smoke marijuana
I use illicit Drugs ( cocaine, heroine, meth, etc.)
I vape

City of Knowledge

Permission To Test for Covid

Requester Authorization:

COVID History Form