Medlab, Walk-In Consent Form
COVID-19 PCR Testing Appointment and Consent Form
Appointment
Who is the test for?
Myself
Child/Dependent
My Patient
Patient Name (individual to be tested)
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Gender
*
Male
Female
Other
Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Phone Number
*
Please enter a valid phone number.
Email
example@example.com
Do you have a prescription from a referring physician?
Yes
No
Prescribing Physician Office
Please Select
Buffalo Ophthalmology
General Physician PC
Orchard Park Pediatrics
WNY Pediatrics
Quaker Medical Associates
Lockport Pediatrics
Other
Other Office
Payment
*
Credit Card
Insurance
Uninsured
Insurance Payer
Please Select
Blue Cross Blue Shield
Independent Health
Fidelis Care
Medicaid
United Healthcare (UHC)
Medicare
Univera
Molina
Other
Other Payer
Policy Number
Social Security Number
Do you currently have any of the following symptoms?
Cough
Sore Throat
Fever
Shortness of Breath
Loss of Smell or Taste
Headache
Have you recently been exposed to anyone with COVID-19?
Suspected exposure
Known exposure
Consent to Bill Insurance
I authorize Medlab to submit payment claim, for laboratory services rendered, to my insurance provider. I understand I am responsible for payment of any denied claims, deductibles, and co-insurance charges. If my health plan providing medical benefits makes payment for laboratory service to me, I understand that I am responsible for making the payment to the laboratory for services rendered.
Consent to Bill HRSA
I do not currently have active health insurance, and authorize Medlab to submit payment claims, for COVID testing services, to the Health Resources & Services Administration under the Cares Act.
Parent or guardian name, if other than individual to be tested
First Name
Last Name
Patient/Parent/Guardian Signature. By signing here, I give Medlab consent to collect specimen and perform COVID019 testing
*
Clear
Submit
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