COVID-19 Rapid Antigen Screening Survey

Would you like to schedule a new appointment or change an existing appointment? *

Schedule a new appointment Change an existing appointment Cancel an existing appointment

To make a change to your appointment time:
1. Scroll down to the Appointment Calendar.
2. Select a new appointment time slot.
3. Scroll to the bottom of the form and press submit.

To cancel your appointment:
1. Scroll down to the Appointment Calendar.
2. Deselect your current appointment time slot.
3. Scroll to the bottom of the form and press submit.

Location: *

801 Broadway Ave NW, Grand Rapids, MI 49504 Special

Password: *

Please ask intake staff for password

Please note this testing location is open Monday, Wednesday, & Friday (9:00am to 5:30pm), Tuesday & Thursday (10am-6pm).

This is a Rapid Antigen Test. If you do not wish to receive this test, please fill out the form for the PCR Test here.

Name *

First Name Middle Name Last Name

Date of Birth *

Email *

example@example.com

Gender *

M F

Race *

Alaska Native American Indian Asian Black or African American Native Hawaiian or Pacific Islander Unknown White or Caucasian Other

Ethnicity *

Hispanic or Latino Not Hispanic or Latino Unknown/Decline to Answer Other

Mobile Phone Number *

Address (Primary Residence) *

Street Address

Street Address Line 2

City State

Zip Code

How Did You Hear About NxGen's Covid Testing?

I clicked on an ad I searched online for testing I saw a billboard Someone told me about it Other

Have you had close contact with a person who has been diagnosed with COVID-19? *

Yes No

Are you experiencing a cough? *

Yes No

Are you experiencing a fever? *

Yes No

Are you experiencing shortness of breath? *

Yes No

Are you experiencing fatigue? *

Yes No

Are you experiencing a sore throat? *

Yes No

Are you experiencing muscle pain or aches? *

Yes No

Are you experiencing headaches? *

Yes No

Are you experiencing diarrhea? *

Yes No

Are you experiencing loss of taste or smell? *

Yes No

Are you experiencing nausea or vomiting? *

Yes No

Do you have any of the following risk factors: cancer, chronic kidney disease, COPD, immunocompromised state from solid organ transplant, obesity, serious heart conditions, sickle cell disease, type 2 diabetes mellitus? *

Yes No

Are you pregnant?

Yes No

If you are experiencing symptoms of COVID-19, what was the date of symptom onset?

Leave blank if it does not apply

Is this your first COVID-19 Test?

Yes No

Rapid antigen testing for COVID-19 is a diagnostic test that quickly and directly detects the presence or absence of SARS-CoV-2, usually within 15 minutes. While rapid antigen testing can provide results quickly, PCR provides the most accurate result and ensures that a false negative has not occurred. Rapid antigen testing is not intended for asymptomatic patients.

Please note: Appointments not canceled within 24 hr of the appointment date and time will incur a $15 fee to cover administrative fees.

*** If you are planning to travel, Rapid Antigen tests are often not acceptable for travel. Check your travel destination's COVID-19 testing requirements carefully to confirm acceptability of Rapid Antigen or Rapid Molecular testing***

This is a Rapid Antigen Test. If you do not wish to receive this test, please fill out the form for the PCR Test here.

Product Details *

Rapid Antigen Test

$ 79.00

Total

$ 0.00

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Schedule Appointment *

Acknowledgment:

I authorize the laboratory to provide my health plan with the information on this form and other information provided by my health care provider if necessary for reimbursement. I understand that the laboratory may seek prior authorization for testing from my health plan on my behalf. I also authorize all benefits from the plan to be payable directly to the laboratory, and I agree to remit to the laboratory any payment for these services made directly to me. I understand that the laboratory may be an out-of-network provider for my health plan and that I am responsible for all amounts not reimbursed by my health plan. I hereby designate the laboratory as my Authorized Representative, as provided under ERISA, 29 C.F.R § 2560.5031 (b)(4), and/or as my Attorney in Fact, for the purpose of pursuing administrative appeals to which I am entitled and, if the laboratory deems it appropriate, any legal and/or equitable claims that I could bring against my health plan, and/or its administrators, with respect to their handling or resolution of my insurance claim.

I understand that in certain circumstances, the laboratory is required to report test data to relevant state public health agencies.

I agree that my de-identified specimen and test data (where information that could link me to the specimen or data has been removed, making it unlikely that I could be identified) may be retained, used and disclosed for research and/or to help develop products or services, in compliance with applicable laws.

I understand that I will not receive any royalties, payments, benefits or rights from any resulting products or discoveries, and that if I do not want my de-identified specimen and test data to be retained, used or disclosed for research or product development purposes I should call Customer Service at 1-855-776-9436.

Patient Signature: *

Clear

Please verify that you are human *

Date

Please Note: This testing location is a drive through location and you should not need to exit your vehicle. It is NOT located in the Clark Place building

COVID-19 Rapid Antigen Test Survey and Screening

Patient Information

Covid-19 Test and Screening

Payment Details