SARS-CoV-2 ANTIGEN TEST QUESTIONNAIRE

Questionnaire Required For Each Patient Being Tested*
I understand that this questionnaire must be completed by each patient being tested.

Are you experiencing symptoms?*
The most common symptoms are fever, loss of taste/smell, nasal congestion, cough, headache, body-aches, chills, nausea/vomiting, diarrhea or rash.
- Yes
- No
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.

NOTE: On Saturdays we typically begin testing at approximately 11:30 a.m. All other days we typically begin testing at approximately 4:00 p.m.
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.

NOTE: On Saturdays we typically begin testing at approximately 11:30 a.m. All other days we typically begin testing at approximately 4:00 p.m.

Are you a new patient?*
- Yes
- No

Pediatric People DOES NOT accept Medicare or Medicaid at this time.*
I understand and agree that Pediatric People does not accept Medicare or Medicaid.
SARS-CoV-2 Antigen Test Agreement*
About the SARS-CoV-2 Antigen Test

1) This visit is for the sole purpose of identifying a COVID infection. It is NOT for management and treatment of any current symptoms. Please see a doctor for treatment if your symptoms worsen or if you have respiratory distress or dehydration.

2) This is a viral test that will tell if you have a CURRENT infection. It will NOT tell us if you've had the virus in the past. Test specimens are obtained from the nose using a nasal swab. Results are typically within 15 minutes.

I have read, understand and agree.

Patient's Name*
First Name Middle Initial Last Name
Patient's Date of Birth*
Patient's Age*
Patient's Gender*
- Female
- Male
Do you have any of these chronic medical conditions?*
- None of these
- Diabetes
- Elevated blood pressure
- Elevated cholesterol
- Asthma
- COPD
- Cancer
- Immunocompromised
- On chemotherapy
Have you ever been hospitalized?*
- Yes
- No
Please list your hospitalizations.*

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.
Phone*
Email*
Enter Email Confirm Email

Why does the patient need a SARS-CoV-2 antigen 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.

Has the patient had a fever?*
- Yes
- No
When did the fever begin?*
Date Format: MM slash DD slash YYYY
What is the highest temperature of the fever since it began?*
When was the last day of a fever greater than 100.4 without fever reducing medications?*
Date Format: MM slash DD slash YYYY

Has the patient had a SARS-CoV-2 test in the past?*
- Yes
- No
When was the SARS-CoV-2 test performed?*
Date Format: MM slash DD slash YYYY
Where was the SARS-CoV-2 test performed?*
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?*
Date Format: MM slash DD slash YYYY
Has the patient been in contact with anyone at school, daycare or work with COVID-19 symptoms?*
- Yes
- No
When were you notified of the exposure?*
Date Format: MM slash DD slash YYYY

Has the patient traveled in the past 2 weeks?*
- Yes
- No
When did the patient travel?*
Date Format: MM slash DD slash YYYY
Where did the patient travel?*
How did the patient travel?*
- Plane
- Car
Has patient attended camp, school, extracurricular activities or working a job during the past 2 weeks?*
- Yes
- No
Where?*
Have parents or patient been working out of the home during the past 2 weeks?*
- Yes
- No
What occupation(s)?*

How would you like to pay for your SARS-CoV-2 Antigen Test?*
I understand and agree that Pediatric People does NOT offer free testing through the CARES Act.
- Insurance
- Self Pay
- Business Account
Do you have a business account that we should be bill for any amount your insurance doesn't pay?*
- No
- Yes
Business Account Number*
By using my employers business account as a full or partial payment method, I understand and agree that Pediatric People, PLLC will ONLY share my SARS-CoV-2 (COVID-19) Antigen Test Results with my employer. I understand and agree that I may may revoke this authorization by submitting a written revocation to Pediatric People’s Director of Administration. There is no expiration of this authorization. However, this authorization can be terminated at any time at the written request of the patient. Information that is disclosed under this authorization may be disclosed again by the person or organization to which it was sent. The privacy of this information may not be protected under the federal privacy regulation.
How would you like to send us photos of your Identification and/or Insurance Card?*
- 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 Identification*
(drivers license or government ID, it must include your address)

Accepted file types: jpg, gif, png, pdf.
Upload Front of Insurance Card*
Accepted file types: jpg, gif, png, pdf.
Upload Back of Insurance Card*
Accepted file types: jpg, gif, png, pdf.
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 for Patients With Insurance*
You understand and agree that you will be required to keep a credit card on file for the SARS-CoV-2 Antigen Test. This card will be charged the amount you are responsible for automatically after your insurance settles the claim. The maximum amount you could be responsible for is $99.
Payment Terms for Self Pay Patients*
You understand and agree that you will be required to keep a credit card on file for the SARS-CoV-2 Antigen Test. The self pay rate is $99 and will be charged to your credit card when you schedule your appointment.
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 or Patient*

Reason	Year

Name of Medication	Reason