Preregistration Form

Covid-19 PCR Test Registration

Booking Information:
Service Requested:
Location
Location ID Hidden
Location Name Hidden
Test Type*
Calendar Visibility Hidden
- No
- Yes
Appointment Day

April 2024

Sun Mon Tue Wed Thu Fri Sat

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Payment Type*
- Credit Card
- Insurance
- No Payment (State Funded)
Payment Total:
Payment Total (Hidden):*
Payment Token (Hidden)
Patient Information:
Patient Name*
First Last
Date of Birth*
Date Format: MM slash DD slash YYYY
Gender*
Race*
Ethnicity*
Address 1:*
Address 2:
City:*
State:*
Zip*
Phone:*
Email:*
Person Completing this Form:
Relationship to Patient
First Name:*
Last Name:*
Gender*
Address Same as Registrant
- Address Same as Registrant
Address 1:
Address 2:
City:
State:
Zip:*
Phone:*
Insurance Information:
Insured relationship to patient
Insured First Name*
Insured Last Name*
Insured date of birth:*
Date Format: MM slash DD slash YYYY
Insurance Company*
Insurance Policy ID*
Insurance Group ID
This lab only accepts insurance patients who are seeking testing for diagnostic purposes. Patients must be experiencing Covid-19 symptoms or have had a potential exposure to Covid-19 to qualify for medically necessary diagnostic test.*
- I acknowledge that I am seeking a diagnostic test.
Additional Questions
First test?*
Health care worker?*
Resident in a congregate care setting?*
Pregnant?*
Hospitalized?*
ICU?*
Symptomatic?*
Date of symptom onset*
Date Format: MM slash DD slash YYYY

(mm/dd/yy)
Fully Vaccinated?*
Consent:
I hereby authorize Dynamic DNA, LLC to perform SARS-CoV-2 PCR on my sample. Turn-around time is 24-72 hours.

This test was developed and its performance characteristics determined by Dynamic DNA Laboratories, LLC. It has not been cleared or approved by the U.S. Food and Drug Administration and is operated as a laboratory developed test. Results should be used in conjunction with clinical findings and should not form the sole basis for a diagnosis or treatment decision. Negative results do not preclude SARS-CoV-2 infection and should not be used as the sole basis for patient management decisions. Negative results must be combined with clinical observations, patient history, and epidemiological information. Dynamic DNA follows federal and state requirements for both notification of results and any confirmatory testing that is required by another agency.

Unlabeled specimens will not be processed or tested. Incorrectly labeled specimens will delay results. The specimen collector is responsible for correct specimen labeling and collection. Specimens will not be sent back to the collector for corrections. If the insurance payment option was selected, I hereby acknowledge and agree that if insurance does not cover the cost of the selected testing I will be responsible for the $100 cost.
Check here to indicate that you have read and agree to the Consent Policy*
I agree to the Consent Policy
Name
This field is for validation purposes and should be left unchanged.

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Covid-19 PCR Test Registration

Booking Information:

April 2024

Patient Information:

Person Completing this Form:

Insurance Information:

Additional Questions

Consent:

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