Alpha Kappa Alpha Sorority, Inc. 69th South Atlantic Regional Conference

Alpha Kappa Alpha Sorority, Inc. 69th South Atlantic Regional Conference

Onsite COVID Testing Provided by Priority Toxicology Laboratories
Alpha Kappa Alpha Sorority, Inc

69th South Atlantic Regional Conference

COVID Testing Registration

Please complete this testing registration prior to presentation to your requested testing station to expedite the testing process.

THANK YOU from Priority Toxicology Laboratories

Jerremy Willis Ph.D., CEO, Owner & Lab Director

Vandy Gaffney II, MD, MS., Onsite Testing Director and Medical Consultant
DATE*

MonthDayYear
Date
Name*

First NameLast Name
Sex

MF
Date of Birth*
Phone*
Address*
City*
State*
Zip*
Email Address*
example@example.com
must select one*

Z20.822 - Contact with and (suspected) exposure to COVID-19Z11.52 - Encounter for screening for COVID-19
Select Desired Test*
Testing Location*
I authorize the release of the results to the ordering clinician, authorized client/representative, or medical review officer. I authorize Priority Toxicology Laboratories to release any information for billing purposes. As the beneficiary of my health insurance, I hereby assign to Priority Toxicology Laboratories my right to coverage and payment for the testing received by me and performed on my behalf by Priority Toxicology Laboratories. I also agree that in a case where my insurance provider sends payment directly to me I will endorse the insurance check and forward to Priority Toxicology Laboratories within 30 days.
Patient Signature*

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