COVID-19 Test Registration

COVID-19 Test

Registration
Instructions- Please read carefully

Thank you for your interest in COVID-19 testing at our office. All Patients over the age of 12 require an e-mail address. All patients 18 and over must complete their own separate forms. The term "child" refers to any patient under the age of 18.
PATIENT INFORMATION

Use this section for ONE ADULT patient OR if completing the form for your CHILDREN
I would like to request the following test(s)*

COVID19 PCR/molecular testCOVID19 Rapid/antigen testI'm not sureBoth COVID PCR and Rapid tests
Please bill:*

Me (Please send us a photo of your Driver's License or Photo ID)My medical insurance plan (It is your responsibility to determine if your insurance will pay for a telemedicine visit and COVID testing at our office. Please send a picture of BOTH your Driver's License or Photo ID and your medical insurance card via Spruce). Let us know if you have any questions. We can help.
Adult Patient or Child 1 Name*

Patient's First NamePatient's Last Name
Adult Patient or Child 1 DOB*

MonthDayYear
Date
Adult Patient or Child 1 Sex*

FemaleMale
Patient Home Address *

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Patient Phone Number *
Please enter a valid phone number.
Patient Email (Use a Parent email for patient less than 12 years old)*
example@example.com
Child/Minor 2 Name

Patient's First NamePatient's Last Name
Child/Minor 2 Sex

FemaleMale
Child/Minor 2 DOB

MonthDayYear
Date
Child/Minor 2 Email (if 12 and older)
example@example.com
Child/Minor 3 Name

Patient's First NamePatient's Last Name
Child/Minor 3 Sex

FemaleMale
Child/Minor 3 DOB

MonthDayYear
Date
Child/Minor 3 Email (if 12 and older)
example@example.com
Child/Minor 4 Name

Patient's First NamePatient's Last Name
Child/Minor 4 Sex

FemaleMale
Child/Minor 4 DOB

MonthDayYear
Date
Child/Minor 4 Email (if 12 and older)
example@example.com
PARENT INFORMATION

Complete only for patients less than 18 years old
Parent/Legal Guardian 1
Name
Parent/Legal Guardian 1 Date of Birth
Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Legal Guardian 1 Cell phone
Parent/Legal Guardian 1 Work phone
Parent/Legal Guardian 1 Email Address
Parent/Legal Guardian 2 Name
Parent/Legal Guardian 2 DOB

MonthDayYear
Date
Parent/Legal Guardian 2 Cell phone
Parent/Legal Guardian 2 Work phone
Parent/Legal Guardian 2 Email Address
example@example.com
If the child or children live with both parents, in the same household, leave the parent 2 address blank.
Parent/Legal Guardian 2 Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Authorization and Agreements
I hereby authorize Friendly Hills Pediatrics to perform collection and testing for exposure to SARS-COV-2 through a nasal swab as ordered by an authorized medical professional.

I understand that Friendly Hills Pediatric's laboratory is operating as permitted under applicable laws and regulations.

By signing, all parties agree to be contacted via telephone, text messaging, and patient portal.

I understand that if I receive a positive test result for myself or my dependent(s), I must ensure that I abide by all applicable local requirements with respect to isolation and quarantine to avoid infecting others.

I understand that testing does not replace treatment by a medical provider. I assume complete and full responsibility to take appropriate action with regards to the test result for myself and my dependents if applicable. I agree I will seek medical advice, care, and treatment from a medical provider for anyone who I am responsible for, if it becomes necessary.

I understand that, as with any medical test, there is the potential for false positive or false negative rest results to occur.

I understand that a copy of the privacy practices of this facility are found on the website friendlyhillspediatrics.com.

I understand that Friendly Hills Pediatrics may release information regarding treatment to third party payors such as Medi-Cal or insurance companies for the purpose of billing.

I understand that COVID-19 is a reportable condition. As such, Friendly Hills Pediatrics will report any positive cases including protected health information to the local health department.

I have been informed about the test purpose, procedures, possible benefits and risks. I have been given the opportunity to ask questions before I consent.

I voluntarily agree to testing for COVID-19 for myself and if applicable, my dependent(s).

I further understand the testing fees are due and payable on the date that services are rendered and agree to pay all such charges incurred at the time of the visit.

I have read and understand all the above statements and agree to uphold the terms and conditions of the above policies of Friendly Hills Pediatrics.
Signature

For patients 17 years old or younger, parent must sign.
Signature

Clear
Printed name (First & Last)
Please go to https://friendlyhillspediatrics.com/covid-19/ for instructions about testing with our clinic.
Thank you for allowing us to care for you today. We pride ourselves in providing high quality care. Please visit our website at www.friendlyhillspediatrics.com to learn more about our practice.

Wishing you good health,

The Friendly Hills Pediatrics Team
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COVID-19 Test

Instructions- Please read carefully

PATIENT INFORMATION

PARENT INFORMATION

If the child or children live with both parents, in the same household, leave the parent 2 address blank.

Authorization and Agreements

Signature

Please go to https://friendlyhillspediatrics.com/covid-19/ for instructions about testing with our clinic.