Consent Form: Saliva LDT COVID-19 RT-PCR Test

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May 24, 2022

No Appointment for selected date

Step 1

Welcome

Do you have insurance?

Yes

Registering Location

Are you doing registration at ?

Drive Through / Event Lab

If you do not have insurance be sure to read the information below

Agreement / Signature
Patient certification: By reading this information, the medical professional acknowledges that the individual/family member authorized to make decisions for the individual (collectively, the “Patient”) has received information regarding the process and consented to undergo selected testing. No test other than the specific test ordered shall be performed on the biological sample.

By eSigning this consent you agree if it is found you have insurance you will be financially responsible for all costs related to this test (approximately one hundred thirty five dollars approx.).

Step 2

Personal Details

First Name*

Middle Name

Last Name*

D.O.B*

Phone Number*

Gender*

Email Address*

Confirm Email Address*

Kit ID

Registration for Individual or Family

Individual Family

Family Details

Enter Second Member Details

Name

Phone

Gender

Relation

Kit ID

Enter Third Member Details

Name

Phone

Gender

Relation

Kit ID

Enter Fourth Member Details

Name

Phone

Gender

Relation

Kit ID

Enter Fifth Member Details

Name

Phone

Gender

Relation

Kit ID

Add Third Member Add Fourth member Add Fifth Member

Street Address*

Suite/Apt#

Address 1

Address 2

Zip Code*

City*

State*

Country*

Passport Number (Only for Travel)

Set Password

Password

Your password must contain at least one lowercase.
Your password must contain at least one uppercase letter.
Your password must contain at least one number (0-9).
Your password must contain at least one special character.
Space between characters is not allowed.
Your password must be between 6 and 30 characters.

Confirm Password

Passwords do not match.

Patient Ethnicity

I consider myself: *

Not Hispanic or Latino

Hispanic or Latino

Do not wish to answer

Patient Race

Which of the following racial designations best describes you (select one or more): *

American Indian or Alaska Native

Asian

Black or African American

Native hawaiian or other Pacific Islander

White

Do not wish to answer

Do You Have Insurance?

Yes No

Step 3 Title

Insurance / Payment Details

Do you have insurance? *

Yes No

How will you be paying? *

Cash Credit Card Insurance

Step 2

Insurance Details

Please enter your SSN number*

Primary Member ID*

Insurance Company*

Please upload images in .jpg and .png format only and up to 2 MB size.

Upload Insurance Front Side*

Upload

Upload Insurance Back Side*

Upload

If you Don't have Insurance, Fill this CARES ACT Consent Form

Please upload images in .jpg and .png format only and up to 2 MB size.

Upload Driving License Front Side

Upload

Upload Driving License Back Side

Upload

If unable to upload DL or State ID Pictures, then fill this

State ID / License Number

Select State

In addition to E-Mail, I want to receive my Patient QR-Code through this notification type:

Text/SMS:

Step 4 Title

Health

I have the following condition(s): *

High blood pressure

Heart disease (e.g. previous heart attacks, heart failure, etc.)

Diabetes

Over weight or obesity

Kidney disease or other neurological condition affecting my ability to cough

Liver disease

Lung disease

Does not apply

I have a condition that weakens my immune system or makes it harder to fight infections: *

HIV

Cancer

Lupus

Rheumatoid Arthritis

Solid organ or bone marrow transplant

Does not apply

I am taking one of these medications: *

Steroids

Chemotherapy

Immunosuppressants

Does not apply

I am or may be pregnant

Yes

I regularly use tobacco or nicotine products (e.g. cigarettes, e-cigarettes, vapes, hookah, etc.)

Yes

Have you possibly been exposed to the Coronavirus in the past 2 weeks? *

Yes

I have been in close proximity (within 6 ft.) to someone who has been diagnosed with or presumed to have COVID-19. *

Yes

I have been in close proximity (within 6 ft.) to someone who is sick but has not been diagnosed with COVID-19. *

Yes

I live, work or have visited a place where COVID-19 is widespread. *

Yes

Step 5 Title

Symptoms

Have you had any of the following symptoms since December 2019: *

Fever, at least 100.3 F, or feeling feverish, or feeling warm to the touch

Dry cough, new or worsening

Sinusitis or sinus pain

Loss of smell or taste

Runny nose or stuffy nose

Chills

Feeling tired, fatigue

Headache

Sore throat, new or worsening

Shortness of breath, particularly with simple activities

Muscle pain/aches or joint pain

Diarrhea

Vomiting

Red/purple bumps on hands or toes/feet, painful or sore to touch

Pink eye

Expectoration (ex phlegm or mucous)

Does not apply

Are you currently experiencing any of these symptoms? *

Yes

How did you hear about us?

Google

Facebook

Word of mouth

News

Other

Please Share the Source

Step 6 Title

What type of test would you like to have?

PCR Saliva (Free)

PCR Saliva/Rapid Antigen Test (18 USD)

Consent Form: PCR Saliva Test

By clicking Agree & Continue, I hereby,

Agree and consent to the PRIVACY POLICY, TERMS OF SERVICE, and the Consent Form: PCR Saliva Test Policy

I am signing as *

The Patient

The Patient's Legally Authorized Representative

Representative Full Name

Witness Full Name

Back Next

G7 REQUISITION Form

PATIENT INFORMATION

First Name

Middle Name

Last Name

Date of Birth

Age

Sex

Street

City

State

Zip Code

Phone

SSN Not Mandatory.

State Identification / Driver's License Not Mandatory.

Please upload images in jpg and png format only and upto 2 MB size.

Upload State Identification / Driving License Front Side

Upload

Upload State Identification / Driving License Back Side

Upload

Agreement / Signature

Patient Certification: By signing this form, the medical professional acknowledges that the individual/family member authorized to make decisions for the individual (collectively, the “Patient") has been supplied information regarding and consented to undergo selected testing. No test other than the specific test ordered shall be performed on the biological sample.

By eSigning this consent you agree if it’s found you have insurance you will be financially responsible for all costs related to this test (approximately One Hundred Thirty Five Dollars).

Yes

Pay for the Kit

Checkout

Shipping Details

Payment

Card holder Name (Full Name as displayed on card)

Enter valid card holder name

Card number

Enter valid card number

CVV

Enter valid CVV

Expiration Date

Billing Zip

Please Enter Billing Zip

Your Price per kit

Shipping Charges

$ 32

Total Payment

$ 32

The Payment of test will be paid by your Insurance Company

please Confirm and Submit

Verify Your Email-ID

We have Sent Verification Code on Your Email ID -
Please check your E-Mail and Enter the validation code we sent there.

If you have not received the Verification Code on SMS/Email, you can

Your Registration is Complete

Payment Failed! Please complete your registration by completing your payment. Click here to complete the payment. Thank you, for registering with G7. Registered QR Code

Save QR Code IMPORTANT: Show this QR code to our experts before doing your test.

Details

First Name

Last Name