Name: Pediatric People
Price range: $

SARS-CoV-2 Rapid Antibody Test Appointment Limitations*
I understand that the SARS-CoV-2 Rapid Antibody Test is ONLY a screening tool to determine a PAST SARS-CoV-2 infection. This test will NOT determine if you currently have a SARS-CoV-2 infection. We cannot give additional diagnosis of any current ill symptoms.
We DO NOT accept Molina Healthcare, Ambetter, Medicare, Medicaid or supplemental plans.*
I understand and agree that Pediatric People DOES NOT accept, Molina Healthcare, Ambetter, Medicare, Medicaid or supplemental plans.

Please select a date and time:*

Has the patient received the COVID-19 vaccine?*
- No
- Yes
What COVID-19 vaccine did the patient receive?*
- Pfizer-BioNTech
- Moderna
- Johnson and Johnson
When did the patient receive the first dose?*
Did the patient receive the second dose?*
- Yes
- No
When did the patient receive the second dose?*

Why does the patient need a SARS-CoV-2 antibody test?*
- Patient was exposed to SARS-CoV-2 but was NOT tested.
- Patient was sick but was NOT tested for SARS-CoV-2.
- Patient was sick and tested POSITIVE for SARS-CoV-2.
- Patient was sick and tested NEGATIVE for SARS-CoV-2.
- Patient needs test for travel.
- Patient received vaccine and needs to check antibodies.

When was the patient exposed?*
When did the patient start experiencing symptoms?*
When was the SARS-CoV-2 test performed?*
Does the patient currently have any symptoms?*
- Yes
- No
We cannot test you until it's been 2 weeks since your symptoms ended. Please visit us again to complete this health questionnaire and schedule your test at that time.

Are you a new patient?*
- Yes
- No
Patient's Name*
First Last
Patient's DOB*
Patient's Age*
Patient's Gender*
- M
- F
Address*
Street Address City State ZIP Code

Does the patient have any of these chronic medical conditions?*
- None of these
- Diabetes
- Elevated blood pressure
- Elevated cholesterol
- Asthma
- COPD
- Cancer
- Immunocompromised
- On chemotherapy
Has the patient ever been hospitalized?*
- Yes
- No
Please list your hospitalizations.*
Reason Year
Does the patient take any medications?*
- Yes
- No
Please list your medications.*
Name of Medication Reason
Does the patient have any drug allergies?*
- Yes
- No
Please list your drugs allergies.*

Communication Consent*
I understand and agree that this authorization allows Pediatric People, PLLC to send an email or text message regarding test results, appointments, referrals, billing or other information regarding your test. (must be a phone number that can receive text messages)
Phone Number*
Confirm Phone Number*
Email*
Enter Email Confirm Email

How would you like to pay for your SARS-CoV-2 Antibody Test?*
I understand and agree that Pediatric People does NOT offer free testing through the CARES Act.
- Insurance
- Self Pay
How would you like to send us photos of your DRIVERS LICENSE and/or INSURANCE CARD?*
If the patient does not have a drivers license, please upload the drivers license of a parent or legal guardian.
- Upload Now
- Send by Text (NOT recommended, may delay your appointment)
Please use your phone to take a photo of the following items and text them to 972-382-5796.
- Drivers License
- Front of Insurance Card
- Back of Insurance Card
Please use your phone to take a photo of the following items and text them to 972-382-5796.
- Drivers License
Please use your phone to take a photo of the following items and text them to 972-382-5796.
- Drivers License
Upload a photo of the Patient or Legal Guardian's DRIVERS LICENSE*
If you are completing this form on behalf of your child, upload your identification. Drivers license or government ID, it must include your address.
Accepted file types: jpg, gif, png, pdf, Max. file size: 512 MB.
Upload a photo of the FRONT of your INSURANCE CARD*
Accepted file types: jpg, gif, png, pdf, Max. file size: 512 MB.
Upload a photo of the BACK of your INSURANCE CARD*
Accepted file types: jpg, gif, png, pdf, Max. file size: 512 MB.
Are you the primary insured?*
- Yes
- No
Who is the primary individual on the insurance policy?*
Full Name Date of Birth Gender Relationship to You
Payment Terms*
I authorize Pediatric People, PLLC to charge my credit card for any and all remaining medical care charges automatically after my insurance claim settles. I understand that my credit card information will be saved for any and all future transactions. This credit card authorization will remain in effect until canceled. There are NO REFUNDS once we process your test.
Payment Terms*
I authorize Pediatric People, PLLC to charge my credit card $99 for the SARS-CoV-2 Antibody Test. I understand that my credit card information will be saved for any and all future transactions. This credit card authorization will remain in effect until canceled. There are NO REFUNDS once we process your test.
Notice of Privacy Practices*
I have reviewed and agree to Pediatric People PLLC's Notice of Privacy Practices dated October 1, 2013. I understand that I may receive a printed copy of this notice upon verbal or written request now or in the future. The notice may also be viewed on our website at PediatricPeople.com.
Consent for Medical Treatment*
There are no court orders now in effect that prohibits me from signing this consent. I do hereby request and authorize the doctor(s) and practice staff of Pediatric People PLLC to perform ALL necessary medical care. I understand that all medical treatments contain inherent risks.
Signature of Legal Guardian, Patient or Cardholder*

SARS-CoV-2 ANTIBODY TEST
SARS-CoV-2 Antibody Test
$0.00
Credit Card Information*
Card Details
Cardholder Name
Comments
This field is for validation purposes and should be left unchanged.

Reason	Year

Name of Medication	Reason

SARS-CoV-2 ANTIBODY TEST HEALTH QUESTIONNAIRE

SARS-CoV-2 ANTIBODY TEST
HEALTH QUESTIONNAIRE