Book an Appointment

Choose the test type

Rapid COVID-19

Rapid COVID-19/Flu A & B

RT-PCR

RSV

Select Date

Select Time

Select Location

First Name

Last Name

Date of Birth

Gender

Ethnic Group

Race

Email Address

Phone No.

Street Address

Address Line 2

City

State

Zip Code

Upload State ID/Driving License Front Image

Do you currently have any medical insurance coverage?

Yes

Primary Insurance Name

Primary Insurance ID Number

Insurance Group

Name of Insured

If other than self, please enter Primary Name & Primary Date of Birth

Name of Insured

Date of Birth

Relationship to Insured

Upload Insurance Front Image

Upload Insurance Back Image

PCP/Dr. Name

Note

Signature

DISCLAIMER: In consideration for receiving the opportunity to participate in COVID-19 testing (hereinafter Testing"), which is provided by Goat Mass Swabs Inc (the "Company"),I hereby release, waive, discharge, covenant not to sue, and agree to hold harmless for any and all purposes Company and their healthcare staff, members, share holders, officers, servants, agents, volunteers, or employees (herein referred to as "indemnitees") from any and all liabilities, claims, demands, injuries (including death), or damages, including court costs and attorney's fees and expenses, that may be sustained by me while participating in Testing, while traveling to and from the Testing, or while on the premises owned or leased by Indemnitees. I am fully aware that the Testing provided by Company may invoice COVID-19 tests that have not gone through a full FDA approval process and instead obtained emergency use authorization (EUA) or registered and are pending such processing and that the results could produce false positives or false negatives, or be admin istered in a way that otherwise produces inaccurate results. I am also fully aware that the Company is not providing medical care or giving a medical diagnosis with Testing and that I should consult my doctor or go to an emergency room if I have a serious symptom and/or to obtain medical advice from my own doctor as to the results of the Testing. I hereby waive my rights regarding protected health information under HIPAA, to the extent necessary to complete the Testing and to allow Company to provide the results (whether positive or negative) of Testing to (1) the organization which has arranged for the testing and (2) local and state public health authorities (which may result in further direct communication from those entities to me for further follow-up contact tracing). Protected health information will not be reused dis closed by Company to any person or entity other than above, except as required by law. Department for COVID-19 testing are provided by Department of Health and Human Services, Health Resources and Services Administration (HRSA). HRSA requires individuals to provide a copy of their state issued identification card and signed attestation that they do not have any medical insurance at the time of test ing. By signing below, I am agreeing to voluntarily testing. In signing this agreement, I acknowledge and represent that I have read it, understand it and sign it voluntarily. 1, the undersigned, understand and grant permission to Goat Mass Swabs Inc to bill my insurance, process claims and collect payment for laboratory services provided.

By submitting, the patient agree to the laboratory terms.

COVID-19 Testing Registration and Virtual Check-in

Already Registered with us before?

COVID-19 Testing Registration and Virtual Check-in

Already Registered with us before? Auto Fill

Already Registered with us before?