COVID-19 Rapid Antigen Testing
Peppermint Pediatrics | 4444 W 126th Street | Zionsville, IN | 46077 | 317-779-3246
This form is HIPAA-compliant and secure.
Rapid antigen and send-out PCR are separate swabs. Neither swab goes deep in the nose (both are anterior nares swabs). All questions regarding symptoms and results should be directed toward your physician. All negative rapid tests will have a send-out PCR performed. Turnaround time for send-out PCRs CANNOT be guaranteed. PCR swabs collected after 2:45pm will be sent to LabCorp on the next business day. Please initial:
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I give permission for Dr. Zee-Cheng to communicate my results via email.
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Yes
No
Reason for testing:
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COVID-19 exposure ONLY - no symptoms
Fever
Cough or congestion
Screening (such as for a trip)
Other
Name
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First Name
Last Name
Date of birth
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Month
-
Day
Year
Date
Legal sex (required by ISDH)
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Email
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example@example.com
Phone Number
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Please enter a valid phone number.
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Insurance information is not used by Peppermint Pediatrics. Peppermint Pediatrics does not process or accept payments from insurance. Insurance information is sent to LabCorp for send-out PCR services. If insurance information is not provided, any additional billing from LabCorp for the send-out PCR will be the responsibility of the patient. Please initial:
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Front of guarantor insurance card (if you get an error message, click again where it says "Use Photo")
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Back of guarantor insurance card (if you get an error message click again where it says "Use Photo"):
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Name of guarantor
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First Name
Last Name
Relationship of guarantor to patient
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Test Options (Refunds are less a 5% processing fee. After-hours fees are not refundable.)
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Add this if you are testing at 6pm or later
$
20.00
COVID-19 RAPID ANTIGEN
Rapid COVID-19 antigen test
$
70.00
COVID-19 RAPID ANTIGEN + RAPID FLU A/B
Rapid COVID-19 antigen test AND rapid influenza A/B test
$
80.00
Credit Card
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