COVID-19 TEST REQUISITION FORM

INFINITY LABORATORIES

(FOR OFFICE USE)

Select Test Type: *

COVID PCR
RAPID ANTIGEN

Lab Name:

Site Location:

FirstName: *

LastName: *

DOB: *

Gender: *

Address: *

Address2:

City: *

State: *

ZIP: *

Phone No: *

Email Address: *

Confirm Email: *

Race: *

Ethnicity: *

Driver License # or State ID #:

Insurance Coverage: *

I have insurance
I do NOT have insurance

Insurance Name:

Insurance Policy #:

Group #:

Social Security #:

Provider/Physician:

Symptoms / Reason For Testing Contact with and suspected exposure to COVID-19Chest Pain
Personal History of COVID-19Headache
CoughConfusion
Shortness of BreathLoss of smell
Fever 100.4 or higherLoss of taste
FatigueNausea / Vomiting
Sore ThroatDiarrhea
ChillsAllergy Symptons
BodyachesNone
Runny NoseTravel
Congestion

Medical Conditions Asthma / BronchitisCoronary Artery Disease
DiabetesStroke
Kidney DiseaseOverwieght / Obesity
Liver DiseasePregnancy
Hypertensionnone of the above
Congestive Heart Failure

Have you been positive for COVID-19 in the past?

Yes
No
Believe so, but was never tested

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Signature

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Disclaimer:
Individuals getting tested must provide their insurance details as the first billing option, in case of an uninsured person taking the test, the test would be billed to the government providing agency. If an individual fails to provide insurance details in-spite being insured their insurance will be billed upon the availability of such information.

I voluntarily consent and authorize the laboratory to conduct collection, testing, and analysis for the purposes of a COVID-19 diagnostic test. I acknowledge and understand that my COVID-19 diagnostic test will require the collection of an appropriate sample through a nasopharyngeal swab, oral swab, or other recommended collection procedures. I understand that there are risks and benefits associated with undergoing a diagnostic test for COVID-19 and there may be a potential for false positive or false negative test results. I assume complete and full responsibility to take appropriate action with regards to my test results. Should I have question or concerns regarding my results, or a worsening of my condition, I shall promptly seek advice and treatment from an appropriate medical provider.