COVID-19 Testing Registration

Covid-19 Testing Helpline: 972-330-2491

REQUIRED INFORMATION FOR PERSON RECEIVING TEST
- One registration form must be completed in full, for each person being tested for COVID-19.
- A new form is required for any repeated testing, as applicable. It is important to provide your insurance information
  so that tests can be processed appropriately.
Full Name *

Legal First Name Middle Name Legal Last Name
Address *

Street Address

Street Address Line 2

City State

Zip Code
Phone Number *
E-mail *

Confirmation Email
Date of Birth *

Month Day Year
Gender
Insurance Information
Person is Insured? *

Yes No, I confirm I do not have health care coverage such as individual, employer-sponsored, Medicare or Medicaid and therefore qualify as uninsured according to the COVID-19 Uninsured Program in the Coronavirus Aid, Relief, and Economic Security (CARES) Act (P.L. 116-136).
Primary Insurance Company Name
Insurance ID
Subscriber Relationship to Patient
Subscriber First Name
Subscriber Last Name
Group Number
Date of Birth

Month Day Year
Please select all that apply: I am *

Someone with symptoms of COVID-19. A close contact of a known positive COIVID-19 case. A healthcare worker. A person with an underlying health condition (i.e. cancer, diabetes). No symptoms/haven't been exposed, just want to get tested (i.e. flight clearance, employer requested).
Upload driver's license ( or Skip and bring to testing site )

Cancel of
Patient Consent Authorization
Patient Signature (or patient representative) *

Clear
Date

Month Day Year
FOR OFFICE USE ONLY
SPECIMEN INFORMATION: Respiratory Nasopharynx Swab Time:______________ Date__________________
TEST RESULTS: RAPID CORONAVIRUS DISEASE (COVID-19) Antigen Nasal Swab - Invalid Negative Positive
Authorizing Provider Name: Ikechukwu Osuji, MD | NPI 140799405. Signature:_______________________________ Date:__________________
Should be Empty:

COVID-19 Testing Registration

REQUIRED INFORMATION FOR PERSON RECEIVING TEST

Insurance Information

Patient Consent Authorization

FOR OFFICE USE ONLY