New Patient Registration

Name*

First NameLast Name

E-mail *

example@example.com

Contact Number:*

Address*

Street Address

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Postal / Zip Code

Date of Birth*

MonthDayYear

Gender*

Ethnicity*

Race*

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Do you have insurance?*

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Upload Picture of your Insurance Card Front side

I authorize First Bio Lab, LLC to receive payments for this bill from my health insurance. With this assignment of benefit, I know I am responsible for the full payment, copayment, co-insurance, or deductibles. If the insurance pays me for the services, I will send the checks to First Bio Lab, LLC . I authorize the release of medical information necessary to process the claim and act as my power of attorney for request of appeal and documents.
I understand that prior to testing, a Covid-19 screening will be performed via tele-medicine by a medical provider.
I authorize testing for COVID-19, through a nasopharyngeal swab or blood draw, as ordered by an authorized medical provider or public health official.
I authorize my test results to be disclosed to the county, state, or to any other governmental entity as may be required by law.
I acknowledge that a positive test result is an indication that I must self-isolate and/or wear a mask or face covering as directed in an effort to avoid infecting others.
I understand that the medical provider who performed the screening is not acting as my primary medical provider, this testing does not replace treatment by my primary medical provider, and I assume complete and full responsibility to take appropriate action with regards to my test results. I agree I will seek medical advice, care and treatment from my primary medical provider if I have questions or concerns, or if my condition worsens.
I understand that the specific medical provider who performed the screening and her employer or legal entity which she represents or has an ownership interest in, cannot be held responsible for any inaccurate test result that may be generated by the screening or testing procedures. I understand that in signing this Informed Consent, I am agreeing to hold the medical provider and any employer or entity for which she has an ownership interest free and harmless from potential liabilities. This means that I cannot sue the medical provider or her employer or any entity in which she has an ownership interest if the test results are not accurate.
I, the undersigned, have been informed about the test purpose, procedures, possible benefits and risks, and I have received a copy of this Informed Consent. I have been given the opportunity to ask questions before I sign, and I have been told that I can ask additional questions at any time. I voluntarily agree to this testing for COVID-19.

I agree and consent to these terms.

Signature Authorizing*

COVID 19 Testing: Informed Consent