Demographics

Outpatient Lab Self-Scheduling

First Name *

Last Name *

DOB *

Phone # *

E-Mail

Sex

Address

City

State

Zip Code

Ordering Physician

Emergency Contact First Name

Emergency Contact Last Name

Emergency Contact Phone #

Next of Kin First Name

Next of Kin Last Name

Next of Kin Phone #

Have you been diagnosed with Covid-19 in the past 10 days or are you under quarantine for Covid-19?

Yes

Are you experiencing and Cough, Fever, Shortness of Breath, Diarrhea, Loss of Taste or Smell?

Yes

Do you consent to treatment? *

Yes

Do you agree with the Financial Agreement? *

Yes

Capture Order Photo

No Image

Capture Insurance Card Photo

No Image

Selfie Photo

No Image

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