Same Day PCR COVID testing

Same Day Rapid PCR COVID TESTING $160

Non Members
You are requesting a SAME DAY RAPID PCR COVID 19 test to be completed today. This is 1 nasal swab and I will swab each nostril. The test takes 30 minutes to result once the specimen is placed into machine. This is not processed thru insurance and will cost $160 to nonmembers of the practice.

*Please do NOT fill out this form if what you read ABOVE is NOT what you want. Go back and select the CORRECT FORM.

· Please complete this form to set up time for testing. Dr. Davidson will call or email you to set up testing time once form received.
Patient Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Sex (male or female)?*
Patient Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Please e-mail results to:*
example@example.com
Phone Number*
Please enter a valid phone number.
Date*

MonthDayYear
Date
Parent / Guardian to Contact with Results*

First NameLast Name
Parent/Guardian Phone Number*
Please enter a valid phone number.
Reason for Test:*
Date Symptoms started (if having symptoms)
Do you want testing in your car or inside office?
Acknowledgements:
1) I understand that I must pay prior to being tested.
2) I understand that Dr. Davidson is not my physician. All questions regarding symptoms and results must be directed toward my own primary care physician.
Date/Time Request - Dr. Davidson will contact you to set up via email/call.
Signature*
Should be Empty:

Same Day Rapid PCR COVID TESTING $160