Today's Date:
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Patient First Name:
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Patient Middle Name:
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Patient Last Name:
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Patient Preferred Name:
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Home Phone:
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Cell Phone
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Work Phone:
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Social Security Number:
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Sex
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Explain:
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Marital Status
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  • Married
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Age:
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Date of Birth:
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Is the patient UNDER 18 years old?
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Legal Guardian Relationship to Patient
  • Parent
  • Other
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Please specify relationship
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Legal Guardian First Name:
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Legal Guardian Last Name:
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Legal Guardian Date of Birth (mm/dd/yyyy)
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Legal Guardian Phone Number
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Legal Guardian E-mail address
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Legal Guardian Full Address
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I attest that I am the legal guardian of the patient named above. I attest that I have the authority to make medical decisions on behalf of the patient named above. I, the legal guardian, do hereby agree and give my consent to Adoni Healthcare Services to administer my COVID-19 test to the patient named above. I authorize this COVID-19 collection and testing. I authorize that the test results be disclosed to the testing entity, to the county, to the state, or to any other governmental entity as may be required by law. I understand that the testing facility/personnel is not acting as the patient's or my own medical provider. I assume complete and full responsibility to take appropriate actions with regard to the test results. I agree the patient will seek medical advice, care, and treatment from his or her own medical provider if I have questions or concerns or if the patient's condition should worsen. I understand that as with any medical test, there is potential for false-positive or false-negative test results. I have been given the opportunity to ask questions before I sign and I have been told that I can ask other questions at any time. I voluntarily agree for the patient to have testing for COVID-19.
Legal Guardian Full Name:
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Date:
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Legal Guardian State/National Photo Identification

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Upload your documents...
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Back Image Upload:
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Race:
  • White
  • Black/African American
  • Asian
  • American Indian/Alaska Native
  • Native Hawaiian/Other Pacific Islander
  • Other
  • Unreported/Declined to Report
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List:
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Race:
  • Hispanic or Latino
  • Non Hispanic or Latino
  • Unreported/Declined to Report
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E-mail address:
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Address Line 1
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Address Line 2
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City
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Country
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State
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Zipcode
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Emergency Contact First Name
Emergency Contact First Name
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Emergency Contact Last Name
Emergency Contact Last Name
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Emergency Contact Phone
Emergency Contact Phone
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Emergency Contact Relationship
Emergency Contact Relationship
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Do you have insurance?
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Primary Insurance Policy Holder
  • Self
  • Spouse
  • Father
  • Mother
  • Family
  • Other
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First Name of Primary Insured
First Name of Primary Insured
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Last Name of Primary Insured
Last Name of Primary Insured
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Insurance ID #
Insurance ID #
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Insurance Company Name
Insurance Company Name
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Group Name
Group Name
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Group Number
Group Number
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Birthdate of Primary Insured
Birthdate of Primary Insured
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Primary Insured Relationship to Patient
Relationship to Patient
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Upload Insurance
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Back Image Needed
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Do you have Secondary insurance?
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Secondary Insurance Policy Holder
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  • Spouse
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  • Mother
  • Family
  • Other
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First Name of Secondary Insured
First Name of Secondary Insured
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Last Name of Secondary Insured
Last Name of Secondary Insured
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Insurance ID #
Insurance ID #
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Insurance Company Name
Insurance Company Name
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Group Name
Group Name
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Group Number
Group Number
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Birthdate of Secondary Insured
Birthdate of Secondary Insured
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Secondary Insured Relationship to Patient
Relationship to Patient
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Upload Insurance
Front Image Needed
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Please upload driver's license or other type of photo identification
Upload File
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Patient First Name:
Patient First Name:
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Patient Middle Name
Patient Middle Name
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Patient Last Name
Patient Last Name
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Today's Date
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Why do you need a COVID-19 test?
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Date and Time of your flight?
Date and Time of your flight?
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Please Specify
Please Specify
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Have you experienced any of the following symptoms in the past 48 hours: fever or chills, cough, shortness of breath or difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose, nausea or vomiting, and/or diarrhea
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Within the past 14 days, have you been in close physical contact (6 feet or closer for a cumulative total of 15 minutes) with: Anyone who is known to have laboratory-confirmed COVID-19? OR Anyone who has any symptoms consistent with COVID-19?
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Are you isolating or quarantining because you may have been exposed to a person with COVID-19 or are worried that you may be sick with COVID-19?
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Do you have heart disease, lung disease, kidney disease, or diabetes?
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Are you a smoker?
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Have you recovered from a documented COVID-19 infection within the last 3 months?
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Are you currently waiting on the results of a COVID-19 test?
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Have you traveled in the past 14 days?
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Have you tested POSITIVE for COVID-19 in the past?
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Is this your FIRST COVID-19 test of any kind?
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Are you employed in health care?
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Do you reside in a congregate care setting such as a shelter?
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Are you pregnant?
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Have you received a COVID-19 vaccine?
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Manufacturer
  • Select
  • Pfizer
  • Moderna
  • Johnson and Johnson
  • Other
Select
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How many doses have you received?
  • Select
  • 1 Dose
  • 2 Doses
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Manufacturer Name
Manufacturer Name
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Date Received
Select a date
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PCR Test vs. Rapid test vs. Antibody test

The polymerase chain reaction (PCR) COVID-19 test is administered via nasal swab and results are obtained in approximately 2-3 days. This test is typically free to patients as the cost is covered by health insurance or government entities.

The rapid COVID-19 test is administered via nasal swab and results are typically obtained in approximately 15-20 minutes. This test is typically NOT covered by health insurance and government entities. The patient must pay out of pocket for this test.

The COVID-19 antibody test requires a blood draw. This test indicates whether a patient has had PRIOR exposure to COVID-19. This test is usually covered by health insurance. It can take at least 2 weeks after infection for COVID-19 antibodies to develop in the body. This test is not meant to indicate an ONGOING COVID-19 infection.

Different entities (such as particular agencies, employers, companies, airlines, healthcare providers, etc) may prefer 1 type of test over the other. Please be sure of the type of test you need prior to scheduling your appointment.
PCR Test vs. Rapid test vs. Antibody test

The polymerase chain reaction (PCR) COVID-19 test is administered via nasal swab and results are obtained in approximately 2-3 days. This test is typically free to patients as the cost is covered by health insurance or government entities.

The rapid COVID-19 test is administered via nasal swab and results are typically obtained in approximately 15-20 minutes. This test is typically NOT covered by health insurance and government entities. The patient must pay out of pocket for this test.

The COVID-19 antibody test requires a blood draw. This test indicates whether a patient has had PRIOR exposure to COVID-19. This test is usually covered by health insurance. It can take at least 2 weeks after infection for COVID-19 antibodies to develop in the body. This test is not meant to indicate an ONGOING COVID-19 infection.

Different entities (such as particular agencies, employers, companies, airlines, healthcare providers, etc) may prefer 1 type of test over the other. Please be sure of the type of test you need prior to scheduling your appointment.
What type of COVID-19 test are you coming in for? You may choose more than 1
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Payment Information

You will NOT be charged at this time.


We keep your card information on file for copays and other visit-related charges. We also use this card information to process the payment for services not covered by your insurance or the Health Resources and Services Administration.
Card Number
Card Number
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Card Expiration Date
Card Expiration Date
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Security Code
Security Code
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Billing Zipcode
Billing Zipcode
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By providing your card information above, you authorize Caring Hands Clinic to charge the card according to the parameters stated above.

Payment Information

The price for rapid COVID-19 tests is $99.

To limit contact, we ask that you provide your payment information on this form. This is NOT required. It is solely for patient convenience. If you enter your card info on this form, you will NOT be charged at this time. We will only charge the card once you have arrived at our office building.

If you choose not to provide payment information on this form, once you have arrived at the office building parking lot, we will call you for the card info or we will send you an electronic payment link.
Payment Card Number (please include dashes)
Payment Card Number (please include dashes)
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Payment Card Expiration date
Payment Card Expiration date
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Payment Card Security Code (CVV)
Payment Card Security Code (CVV)
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Payment Card Billing Zip Code
Payment Card Billing Zip Code
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By providing your card information above, you authorize Caring Hands Clinic to charge the card according to the parameters stated above.

Consent

I, {first_name_consent} {last_name_consent}, do hereby agree and give my consent to Caring Hands Clinic to administer my COVID-19 test. I authorize this COVID-19 collection and testing. I authorize that my test results be disclosed to the testing entity, to the county, to the state, or to any other governmental entity as may be required by law. I understand that the testing facility/personnel is not acting as my medical provider. I assume complete and full responsibility to take appropriate actions with regard to my test results. I agree I will seek medical advice, care, and treatment from my medical provider if I have questions or concerns or if my condition should worsen. I understand that as with any medical test, there is potential for false-positive or false-negative test results. I have been given the opportunity to ask questions before I sign and I have been told that I can ask other questions at any time. I voluntarily agree to testing for COVID-19.
Patient First Name
Patient First Name
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Last Name
Last Name
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Patient Signature
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Date
Select a date
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Important

Once you arrive, please STAY IN YOUR VEHICLE. Please call or text 240-241-4989 to inform us that you have arrived. If you send a text, please include your full name. We will let you know when to come in.