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Monday

September 26, 2022

No Appointment for selected date

Step 1

Welcome

Do you have insurance? *

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

Set 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.
  •   Passwords do not match.
Patient Ethnicity
I consider myself: *
Patient Race
Which of the following racial designations best describes you (select one or more): *

Step 3 Title

Insurance / Payment Details

Do you have insurance? *
How will you be paying? *

Step 2

Insurance Details


Upload Insurance Front Side*
Upload Insurance Back Side*

Upload Driving License Front Side
Upload Driving License Back Side

Step 4 Title

Health

I have the following condition(s): *
I have a condition that weakens my immune system or makes it harder to fight infections: *
I am taking one of these medications: *
I am or may be pregnant
I regularly use tobacco or nicotine products (e.g. cigarettes, e-cigarettes, vapes, hookah, etc.)
Have you possibly been exposed to the Coronavirus in the past 2 weeks? *
I have been in close proximity (within 6 ft.) to someone who has been diagnosed with or presumed to have COVID-19. *
I have been in close proximity (within 6 ft.) to someone who is sick but has not been diagnosed with COVID-19. *
I live, work or have visited a place where COVID-19 is widespread. *

Step 5 Title

Symptoms

Have you had any of the following symptoms: *
Are you currently experiencing any of these symptoms? *
How did you hear about us?

Step 6 Title

Forms

Global Diagnostic Labs, LLC

Global Diagnostic Lab

PATIENT CONSENT FOR ANTIGEN AND RT-PCR COVID-19 TEST


Name: _________________________________________________ Date of Birth: ____/____/______

Home Address: _______________________________________________________________________________

INSURANCE INFORMATION (OMIT IF CASH PAY)

INSURANCE PROVIDER: ________________________________________________________________

MEMBER ID: _______________________________________________________________________

GROUP NUMBER: _________________________________________________________

INSURED NAME and DATE OF BIRTH: __________________________________________________

RELATIONSHIP TO INSURED: ________________________________________________________________

I authorize Global Diagnostic Labs, LLC (“Global”) to collect a saliva sample from me and conduct RT-PCR COVID-19 testing of the collected sample. I understand that RT-PCR COVID-19 and Antigen testing services by Global are in accordance with the Federal COVID-19 Pandemic Emergency Declaration.

  1. I acknowledge and understand that there are risks and benefits associated with undergoing a RT-PCR COVID-19 test, and there is the potential for false positive or false negative test results. The RT-PCR COVID 19 test being administered does not provide a medical diagnosis of COVID-19 or any other disease. The test result provides information for my healthcare provider to assist in determining whether I should receive further testing or medical treatment. Further, I understand that the RT-PCR COVID-19 tests administered by Global have not been cleared or approved by the U.S. Food and Drug Administration (“FDA”), but have been authorized under an emergency use authorization granted by the FDA. I assume complete and full responsibility to take appropriate action with regards to my test results. Should I have any questions or concerns regarding my results, I shall promptly seek advice and treatment from a medical provider.
  2. I understand that I have a right to confidential treatment of my test sample and test results. I understand that I will receive the test results from Global. I authorize representatives of Global to review my test results and to disclose such test results to county, state, or any other governmental entity as may be required by law.
  3. I understand that Global will have access to my sample(s) and that my sample(s) will be used only for the purposes for which I have given my consent or as allowed under applicable law. I understand samples will be discarded within 48 hours of testing. If a specimen is used for research and development, the specimens are not individually identifiable, i.e., the subject's identity is not known and can not be ascertained by the research team or any other individuals associated with the research.
  4. I understand and acknowledge that Global and its affiliates, representatives and agents are administering RT- PCR COVID-19 testing services only and are not providing any medical or other healthcare services. I authorize Global to communicate with other medical providers regarding my treatment and care as it relates to RT-PCR COVID-19 testing services. I may seek such healthcare services beyond those addressed in this consent from a healthcare provider of my own choosing.
  5. I authorize Global to bill my insurance provider for the RT-PCR COVID-19 testing services performed by Global. I understand that I am financially responsible for the services rendered by Global.
  6. I authorize Global to use the information contained herein to contact me for matters related to healthcare treatment, including eligibility for free testing kits provided by the federal government.

I hereby affirm that I have read and understand this document, had the opportunity to ask questions and consult with a medical provider of my choosing, had the opportunity to seek additional medical opinions, and received satisfactory answers to all of my questions.

I understand and accept all risks contained in this document and give my informed consent voluntarily to receive a RT-PCR COVID-19 Test from Global. If applicable, I authorize Global to bill my health insurance provider for the services rendered consistent with this consent.

Patient Name: _________________________ Signature: ___________________________ Date: ___ / ___ / _____

INFINITY WELLNESS SOLUTIONS, LLC

INFINITY WELLNESS SOLUTIONS

PATIENT CONSENT FOR NEW AND/OR ESTABLISHED PATIENT E&M OFFICE VISIT (INTERACTIVE AUDIO/VIDEO)


Name: _________________________________________________ Date of Birth: ____/____/______

Home Address: _______________________________________________________________________________

INSURANCE INFORMATION (OMIT IF CASH PAY)

INSURANCE PROVIDER: ________________________________________________________________

MEMBER ID: _______________________________________________________________________

GROUP NUMBER: _________________________________________________________

INSURED NAME and DATE OF BIRTH: __________________________________________________

RELATIONSHIP TO INSURED: ________________________________________________________________

I authorize INFINITY WELLNESS SOLUTIONS, LLC to NEW AND/OR ESTABLISHED PATIENT E&M OFFICE VISIT (INTERACTIVE AUDIO/VIDEO).

  1. I acknowledge and understand that there are risks and benefits associated with NEW AND/OR ESTABLISHED PATIENT E&M OFFICE VISIT (INTERACTIVE AUDIO/VIDEO). I assume complete and full responsibility to take appropriate action with the results of NEW AND/OR ESTABLISHED PATIENT E&M OFFICE VISIT (INTERACTIVE AUDIO/VIDEO). Should I have any questions or concerns regarding my results, I shall promptly seek advice and treatment from a medical provider.
  2. I understand that I have a right to confidential treatment. I understand that I will receive NEW AND/OR ESTABLISHED PATIENT E&M OFFICE VISIT (INTERACTIVE AUDIO/VIDEO) from INFINITY WELLNESS SOLUTIONS, LLC. I authorize representatives of INFINITY WELLNESS SOLUTIONS, LLC to review my results and to disclose such results to county, state, or any other governmental entity as may be required by law.
  3. I understand that INFINITY WELLNESS SOLUTIONS, LLC will have access to my results and that my results will be used only for the purposes for which I have given my consent or as allowed under applicable law.
  4. I understand and acknowledge that INFINITY WELLNESS SOLUTIONS, LLC and its affiliates, representatives and agents are administering NEW AND/OR ESTABLISHED PATIENT E&M OFFICE VISIT (INTERACTIVE AUDIO/VIDEO) only and are not providing any other medical or healthcare services. I understand that I must seek such healthcare services from a healthcare provider of my own choosing.

I hereby affirm that I have read and understand this document, had the opportunity to ask questions and consult with a medical provider of my choosing, had the opportunity to seek additional medical opinions, and received satisfactory answers to all of my questions.

I understand and accept all risks contained in this document and give my informed consent voluntarily to receive NEW AND/OR ESTABLISHED PATIENT E&M OFFICE VISIT (INTERACTIVE AUDIO/VIDEO) from E&M OFFICE VISIT (INTERACTIVE AUDIO/VIDEO). If applicable, I authorize NEW AND/OR ESTABLISHED PATIENT E&M OFFICE VISIT (INTERACTIVE AUDIO/VIDEO) to bill my health insurance provider for the services rendered consistent with this consent.

Patient Name: _________________________ Signature: ___________________________ Date: ___ / ___ / _____

Step 7 Title

What type of test would you like to have?