NEW Patient intake. Please fill out to the best of your abilities, you can always make changes at the front desk.
Full Name (required)
Gender (required) MaleFemaleOtherPrefer not to say
Date of Birth (required)
Picture ID (required)
Your Address (required)
Your Email (required)
Your Cell Phone Number (required)
Last 4 digits of Social (required)
Do you have Health Insurance? (required) YesNo
Insurance Card Photo
Current Temperature if possible
Have you been tested before? (required) YesNo
Test Results? (required)
Please enter any symptoms below (required)
Recent Exposure? (required) YesNo
Picture of Yourself (required)
Type of Testing to Perform? Nasal Swab - SARS-CoV2, RT-PCR This test has been authorized by the FDA under an emergency use authorization (EUA) Rapid antibodies: tests for antibodies primarily to check if you have had the virus in the past and current (test results in 15 min). - Free for uninsured and insured covered patients
Testing Location or Area? (required)
Expected Date of Visit (required)
Parental/Guardian Signature if under 18 years of age
Signing Date (required)
Please carefully read and sign the following Informed Consent:
I, the undersigned, have been informed about the test purpose, procedures, possible benefits and risks, and I have received a copy of this Informed Consent. I have been given the opportunity to ask questions before I sign, and I have been told that I can ask additional questions at any time. I voluntarily agree to this testing for COVID-19.
You agree that you are not obligated to test at our center, and understand that we are a private practice charging separately for testing. Your insurance will pay the labs directly as we collect your insurance information, your payment to us is NOT a co-payment or deductible of any sort.
By Clicking the submit button, I agree to terms and conditions.
Ph: (800) 684-4FMC - Info@TheFamilyMedGroup.com
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Ph: (786) 349-4753 - Fax: (877) 811-1792 239 N Krome Ave Ste A, Homestead, FL 33030
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