Name: Pediatric People
Price range: $

SARS-CoV-2 TEST
HEALTH QUESTIONNAIRE

"*" indicates required fields

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Calendar Override

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Payment Override

, are you a new patient?*

Yes

No
Has your insurance information changed?*

Yes

No
What is 's date of birth?*
STOP! If the age below is not correct, please adjust the date of birth.
Is this 's age:*
What is 's gender?*

M

F
What is 's address?*
Street Address City State ZIP Code

Does have any of these chronic medical conditions?*
None of these
Diabetes
Elevated blood pressure
Elevated cholesterol
Asthma
COPD
Cancer
Immunocompromised
On chemotherapy
have you had any past surgeries?*

Yes

No
Please list any past surgeries.*
Reason
Year

do you take any medications?*

Yes

No
Please list your medications.*
Name of Medication
Reason

do you have any drug allergies?*

Yes

No
Please list your drugs allergies.*

does anyone live with you?*

Yes

No
Who lives with you?*

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)
We will send a SMS message with CHECK-IN instructions and your results to this number.
Phone Number*
Confirm Phone Number*
We will send an email to this address containing CHECK-IN instructions and a document with your official results. Check your SPAM/Junk folder if you don't see it.
Email*
Enter Email Confirm Email

STOP!
We cannot send email to Yahoo accounts. Please enter another email address to continue. You will not be able to finalize the appointment.
STOP!
You cannot schedule an appointment because you didn't show up to a previously scheduled appointment.

Why does the patient need a SARS-CoV-2 test?*

Patient is currently sick.

Required by a company, employer, school or daycare.

Required for travel.

Required for surgery.

Possible exposure to COVID-19.
IMPORTANT INFORMATION FOR PATIENTS EXPERIENCING SYMPTOMS
Your test results will be MOST accurate after symptoms develop. Please consider testing or retesting during this time. The most common symptoms are fever, loss of taste/smell, nasal congestion, cough, headache, body-aches, chills, nausea/vomiting, diarrhea or rash.
IMPORTANT INFORMATION FOR PATIENTS NOT EXPERIENCING SYMPTOMS
Your test results will be the MOST accurate 5-7 days after exposure. Please consider testing or retesting during this time or if you develop symptoms such as fever, loss of taste/smell, nasal congestion, cough, headache, body-aches, chills, nausea/vomiting, diarrhea or rash.

What are the patient's symptoms?*
(check all that apply)
Nasal congestion
Shortness of breath or difficulty breathing
Fever
Cough
Headache
Body-aches
Chills
Nausea/vomiting
Diarrhea
Rash
Loss of taste or smell
When did the symptoms begin?*
MM slash DD slash YYYY

When did the fever begin?*
MM slash DD slash YYYY

When was the last day of a fever greater than 100.4 without fever reducing medications?*
MM slash DD slash YYYY

When did the rash begin?*
MM slash DD slash YYYY

Where is the rash located?*

Has the patient had COVID-19 vaccine?*

Yes

No
Has the patient had a SARS-CoV-2 test within the past 2 weeks?*

Yes

No
What was the SARS-CoV-2 test result?*

Positive

Negitive
Has the patient been in contact with anyone at home with COVID-19 symptoms?*

Yes

No
When did their symptoms begin?*
MM slash DD slash YYYY

Has the patient been in contact with anyone at school, daycare or work with COVID-19 symptoms?*

Yes

No
What is the patient's occupation?*

Hidden
We are able to test you for the flu with the same nasal swab used for your Covid-19 test. There's no additional charge for this service. Would you like to add the flu test?*

Yes

No
Hidden
Add PCR*

Yes

No

Patients testing positive for influenza (the flu) who are 18 years of age or greater and have chronic medical conditions may need to contact their primary care physician for medical management of influenza.
How would you like to pay for your 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, your appointment may be canceled without notice)
You told us that your insurance has changed. Please upload your new card now.
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 FRONT of your new 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.
Upload a photo of the BACK of your new INSURANCE CARD*
Accepted file types: jpg, gif, png, pdf, Max. file size: 512 MB.
You chose NOT to upload your insurance information now. Your appointment will be CANCELED without notice if we do not receive the information within one hour.*
I understand.
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 for the SARS-CoV-2 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 SARS-CoV-2 Test*
There are no court orders now in effect that prohibits me from signing this consent.
Signature of Legal Guardian, Patient or Cardholder*
CAPTCHA
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Test Type*

COVID

COVIDFLU

PCR

SARS-CoV-2 Test
Total

A credit card is required to cover any charges that are not covered by your insurance. The temporary credit card authorization of $99 will remain on your credit card account for 7-days.
A credit card is required to cover any charges that are not covered by your insurance. The temporary credit card authorization of $99 will remain on your credit card account for 7-days.
The PCR test is self pay only.
Credit Card Authorization*
Card Details
Cardholder Name

STOP
We cannot send email to Yahoo accounts. You cannot proceed until you go back and change your email address.
ONLY CLICK THE SUBMIT BUTTON ONCE.

SARS-CoV-2 TEST HEALTH QUESTIONNAIRE

Your appointment time will be held for 10 MINUTES while you complete the questionnaire.

SARS-CoV-2 TEST
HEALTH QUESTIONNAIRE