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Patient Registration

Information that we will need:

1
Authorization
2
Address
3
Symptoms
4
Screening
5
Identification
6
Insurance
7
Test kit barcode
8
Consent
9
Cost of visit
Authorization
What is your cell phone number?
Address
Enter the home or work address where you will be testing.
Select state
Symptoms
Screening
Have you or anyone in your household had any of the following symptoms in the last 10 day: sore throat, cough, chills, body aches for unknown reasons, shortness of breath for unknown reasons, loss of smell, loss of taste, fever at or greater than 100 degrees Fahrenheit?
Are you or anyone in your household a health care provider or emergency responder?
Have you or anyone in your household cared for an individual who is in quarantine or is a presumptive positive or has tested positive for COVID-19?
Have you or anyone in your household been tested for COVID-19?
Have you or anyone in your household visited or received treatment in a hospital, nursing home, long-term care, or other health care facility in the past 30 days?
In the past 10 days, have you been in close proximity to anyone who was experiencing any of the above symptoms?
In the past 10 days, have you been in close proximity to anyone who has tested positive for COVID-19?
Have you tested positive for COVID-19 in the last 5 days? (Patients must wait 5 days from a positive test date before re-testing)
Do you have any reason to believe you or anyone in your household has been exposed to or acquired COVID-19?
Identification
    No Identification source
    Driver's License
Please note: Only the following file types will be accepted: .jpg, .png, .bmp, .gif.
Insurance
On March 15th, 2022, the US Health Resources & Services Administration (HRSA) announced that it would no longer be funding COVID-19 testing or treatments. As a result, all of Sick.org’s COVID-19 services will now be billed through your insurance provider. Patients who are uninsured will be charged a reduced fee of $89.00 for the test sample collection with a care provider, payable by debit or credit as part of the booking process.
  • Please note: Only the following file types will be accepted: .jpg, .png, .bmp, .gif.
  • $89.00
Test kit barcode

Find the barcode on the vial and enter the code in the field below:

Consent

PERMISSION TO CONDUCT DIAGNOSTIC TESTING

I give Vital Urgent Care, Inc. and Pangea Laboratory, LLC permission to conduct the requested diagnostic testing on my specimens.

ASSIGNMENT OF BENEFITS

I acknowledge that the information provided by me is true to the best of my knowledge. For direct insurance billing, I hereby authorize my insurance benefits to be paid directly to Vital Urgent Care, Inc. and Pangea Laboratory, LLC, and I authorize them to release medical information concerning my testing to my insurer. I authorize Vital Urgent Care, Inc. and Pangea Laboratory, LLC to be my Designated Representative for purposes of appealing any denial of benefits. I acknowledge and agree that Vital Urgent Care, Inc. and Pangea Laboratory, LLC have the right to request additional medical records, such as consult notes, directly from my provider(s) for the purpose of insurance verification and proper billing. I also fully understand that I am legally responsible for sending Vital Urgent Care, Inc. and Pangea Laboratory, LLC any monies received from my health insurance company for the performance of any laboratory testing.

LEGAL AGE AND GUARDIANSHIP CONFIRMATION

By signing, I acknowledge that I am at least 18 years of age or am the parent or legal guardian of the person who is registering for an appointment.

By placing my signature below, I certify that the information on this patient registration is correct and I fully understand and agree with the following:

Clear
Cost of visit

Some same-day appointments may include a delivery fee in order due to high demand in the area.

Covid-19 test
$0.00
Total cost $0.00
Payment is available after verification
On App store
Urgent Care
Primary Care
COVID-19
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© 2023 Sick.org. All rights reserved.
Testing CentersPCR TestsRapid Antigen TestsLong Haul COVIDAt Home Testing
Telemedicine Consults
Concierge Sign In
Concierge
Get support and recommendation

Thank you for using Sick.org's at-home PCR COVID-19 test. Before you begin, please prepare the sample collection tube by following the steps below: 1. Remove the PCR collection tube from the sealed package. 2. Under "Name" - Please enter your Full Name (FIRST and LAST name). 3. Under "Date" - Please enter your Date of Birth in MM/DD/YYYY format (for example: May 1, 1980 would be 05/01/1980). 4. Once complete, please click on the Get Started button below to register your test and collect your sample. Feel free to Text or Call: +1 (888) 215-6182 if you have questions.

On App store
Urgent Care
Primary Care
COVID-19
Company
© 2023 Sick.org. All rights reserved.