Covid Test Form

NOVA Medical Center

8702 Sudley Rd, Manassas VA 20110|Ph:703-361-4357|Fax: 703-361-0346| Text: 703-348-3535
Patient Information
Patient Name:   First Name*   Last Name*  Full Address:   *
Phone:   Phone Number*  Email: Email*   Date of Birth:   Date*
Sex :   *    Marital Status:   *
Do you have Insurance? Yes No*
Insurance Information
Primary Insurance Carrier:   *   Phone:      Phone Number*
ID:       Group:
Name of Policy Holder:   *  Date of Birth:   Date*
Are you vaccinated COVID-19? 1st Dose 2nd Dose Booster*
Reasons for Test: Travel Return to Work Symptoms Other*

Please answer all the following questions *

	Yes	No
Have you or anyone in your household had any of the following symptoms in the last 14 days ? (Sore Throat, Cough, Chills, Body ache for unknown reasons ,Shortness of breathe for unknown reasons ,Loss of smell / loss of taste ,Fever at or greater than 100 degree Farenheit)
Have you or anyone in your household been tested positive for COVID-19 ?
Have you or anyone in your household cared for an individual who is in quarantine or is a presumptive positive or has tested positive for COVID-19 within the last 14 days?
Do you have any reason to believe you or anyone in your household has been exposed to or acquired COVID-19 within the last 14 days?
To the best of your knowledge have you been in close proximity to any individual who tested positive for COVID-19 within the last 14 days?
Person protective equipment is required for your examination. Are you willing to wear for the duration of your evaluation?

I authorize my insurance benefits to be paid directly to the physician and I agree to be financially respossible for all charges incurred. I hereby consent to the release and redisclosure of my medical records to enable or facilitate the collection, verification or settlement of my account for any amounts due from me or any third party payer, HMO or other health benefit plan. This consent applies to Altmed or any of its affiliates. I agree to pay for service rendered to me or the above named patient at the time of services or the first statement mailed by Altmed. I promise to pay my account when due and should this account become delinquent and collection becomes necessary, the undersigned agrees to be responsible for attorney's fees of thiry-three and one third percent(33 1/3%) , interest at eighteen percent(18%) per annum from the last date of payment and any and all applicable court costs. I further agreee to pay for my any reasonable fees for missed appointments of which I did not notify the medical office at least 24 hours prior to your appointment. In the event that a check is returned for insufficient fund you are responsible for $35.00 return fees. I {input17:firstname-9} {input17:lastname-9}, as the financially responsible party to the above named patient agree to the aforementioned statements and authorize payment of medical benefits to Altmed for services rendered.
Signature : Signature* Date: Date*
Should be Empty: