COVID-19 Antibody Test Request

COVID-19 Antibody Test Request
Patient Demographic Information
Name
First NameLast Name
Address
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
Email
example@example.com
Phone Number
Area CodePhone Number
Patient Health Information
1) Have you had any of the following symptoms in the last 24 hours?*
Yes No
Cough
Shortness of breath of difficulty breathing
OR at least TWO of the following symptoms in the last 24 hours:*
Yes No
Fever (usually 100.4 or higher)
Chills
Repeated shaking with chills
Muscle pain
Headache
Sore throat
New loss of taste or smell
If you answered “Yes” to question one, please DO NOT come into work. You should:
- Self-quarantine for at least 10 days from the date on which you first experienced any of the above symptoms; AND
- Wait until you have had no fever for at least 3 days (without the use of fever-reducing medication) AND
- Improved respiratory symptoms (no cough, shortness of breath)
2) In the last 7 days have you:*
Yes No
tested positive for Covid-19 by a molecular (PCR) test

	Yes	No
tested positive for Covid-19 by a molecular (PCR) test

3) In the last 10 days have you:*

	Yes	No
Experienced loss of smell or taste
Experienced shortness of breath, weakness or lethargy?
Experienced lightheadedness or dizziness
Experienced vomiting or diarrhea, slurred speech or seizure

4) In the last 14 days have you:*
Yes No
Been in contact with someone who was diagnosed with COVID-19?
Been in close contact with someone who had COVID-19 symptoms?
Traveled internationally or taken a cruise
Request appointment*
I certify to the best of my knowledge; this information is accurate.
Signature*
Clear
Name*
First NameLast Name
Date*
MonthDayYear
Date
My Products
prevnext( X )
Medical Provider review and platform fees (Due now)$49.99

COVID-19 igG Antibody Test * (Due at Point of Care)$55.00

Sample Collection fees (Due at Point of Care)$20.00

Total $0.00
The payment is ready! It will be completed once you submit the form.
Confirm Request and Agree to Terms
Total due now: $49.99
Total due now includes the medical provider review and platform fees only. By clicking"Submit", you indicate that you, as the patient or legal guardian of the patient, agree:
1. to follow up with my regular medical provider for ongoing care;
2. to the best of my knowledge, all information submitted is accurate;
3. to the Terms of Service and Consent to Telehealth.
4. I understand that the total due now does not include any POC fees and that I am responsible for any fees billed by the Pharmacy.
Should be Empty:

	Yes	No
Fever (usually 100.4 or higher)
Chills
Repeated shaking with chills
Muscle pain
Headache
Sore throat
New loss of taste or smell

	Yes	No
Been in contact with someone who was diagnosed with COVID-19?
Been in close contact with someone who had COVID-19 symptoms?
Traveled internationally or taken a cruise

	Yes	No
Cough
Shortness of breath of difficulty breathing

Patient Demographic Information