Fill out this form for each patient. Text a picture of the front and back of medical card to 423-358-2990.
This test has a $20 admin fee, HSA funds may be used to cover the cost. Lab processing is provided under insurance.
(Family members with same address and insurance information may fill out once and skip on additional family members.)
street address, apt #, lot #
REQUIRED FOR BILLING
A member of the pharmacy staff will call to schedule testing appointment
Example: recent travel (please include location), contact with another lab-confirmed COVID-19 case, clearance for surgery, return to work, etc.)
Pre-existing medical conditions
Consent and Date
I give Surgoinsville Pharmacy consent to perform the test and evaluation most appropriate for myself or child. I consent for the lab to bill my insurance as appropriate.
Medical Insurance Information (not pharmacy card)
example (BCBS, United Healthcare, etc.)
Please include street address, city, state, and zip code (Located on back of insurance card)
Additional Screening Questions