Covid-19 Rapid PCR Molecular Test Form-$150

Covid-19 Rapid PCR Molecular Test Form-$150
Patient Full Name
Collected Date

Month Day Year
Date
Received Date

Month Day Year
Date
Phone: 609-261-9919
Report Date

Month Day Year
Date
Fax
SARS21-26653
PATIENT INFORMATION
PHARMACIST INFORMATION
Name
DOB
Age
Soc. Sec. No.
Sex
Med. Rec. #
CLINICAL HISTORY: r/o COVID19 by SARS CoV-2 RNA (COVID 19) QUALTATIVE NAAT
CLINICAL HISTORY
DIAGNOSIS
COVID-19 RT-PCR:
SWAB
Comment: APTIMA SARS CoV-2 assay combine with technologies of target capture TMA/DKA. Positive result indicate the presence of COVID viral RNA, but the clinical correlation with patient history and other diagnostic information is necessary to determine infection status. Negative results should be considered in the context of a patient's recent exposures, history and the presence of clinical signs and symptoms consistent with COVID-19. This test has been authorized by FDA under an Emergency Use Authorization (EUA A nasopharyngeal specimen is the preferred choice for swab-based SARS-CoV-2 testing.
Gaurav Patel, PharmD, Electronically Signed

Clear
Date

Month Day Year
Date
GROSS DESCRIPTION
SWAB
Comments
CPT CODES: U0003, 99212, 99202 ICD-9 CODES: Z20.828
Coivd-19 Rapid rt-PCR Molecular Test *
prev next ( X )
Covid-19 Rapid rt-PCR Molecular Test
$ 150.00

Total

$ 0.00

Pay with Credit Card

Debit or Credit Card

Please click one of the PayPal options to complete payment and submit the form.