ilift info

Name *

First

Middle

Last

Gender

Date of birth *//

Do you have a social security number? *

Social Security Number *

Identification *

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File uploads may not work on some mobile devices. If you do not have a U.S. issued ID, please upload any identification you have available.

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Race *

Ethnicity *

Email

Phone *

Are you experiencing covid19 symptons? *

When was your onset date? *//

What symptoms are you experiencing? *

Shortness of breath/difficulty breathing
Congestion/runny nose
Cough
Fever or chills
Fatigue
Head/muscle/body aches
New loss of taste or smell
Sore throat
Nausea or vomiting
Diarrhea
Acute respiratory distress syndrome (ARDS)
Acute bronchitis due to other specified organisms
Unspecified acute lower respiratory infection
Other viral pneumonia
Influenza due to unidentified influenza virus with other respiratory manifestations
Other specified respiratory disorders

Why are you getting tested today? *

Contact with and (suspected) exposure to CoV19?

Is this your first Covid test? *

Are you employed in healthcare? *

Are you currently hospitalized? *

Are you currently in ICU? *

Are you a resident in a congregate care setting (ie. Nursing home, residential care, etc.)? *

Are you currently pregnant? *

Do you have insurance? *

I do hereby attest that I do not hold an active insurance coverage at this point in time individually or through my employer or through any state or federal programs to the best of my knowledge. *

Under the CARES act, all uninsured CoV19 claims go under a rigorous eligibility check. In the event that we find that you have active insurance policy, it will be billed.

Please be sure to provide accurate insurance information. In the event that your insurance is invalid or you choose to provide inaccurate insurance information and your claim is denied, you may be billed directly. Have you read the above disclosure? *

Front of Insurance Card *

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Back of Insurance Card *

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Relationship to patient *

Signature of Patient/Responsible Party *

Use your mouse or finger to draw your signature above.