BioVision Group COVID-19 Test Registration

Location:

Date and Time: (Please select an open time)

First Name:

Last Name:

Date of Birth:

Gender:
Male Female

Address:

City:

State:

Zip Code:

Mobile Phone:

Email:

Primary Insurance:

Subscriber ID:

Group Reference:

Secondary Insurance: (Optional, if covered)

Subscriber ID:

Group Reference:

State / Passport ID (Int'l Travel): (Optional)

Employer Reference ID: (Optional)

Primary Physician: (Optional)

Physician Phone: (Optional)

Please let us know the following to help prioritize your test -

Current Symptoms:

Current Medical History:

Asthma or chronic lung disease
Cancer (current or previous)
Cirrhosis of the liver

Diabetes
COPD / Lung disease
Kidney failure or ESRD

Obesity (BMI over 30)
Serious heart condition
Weakened immune system

Additional Questions:

I have been exposed to someone who tested positive

I have been prioritized for testing by a medical professional

I work in health care or work/live a setting where the risk of COVID-19 transmission is high

Copy of Photo ID and Insurance Card: (Optional)
Taking a photo of your state-issued ID and insurance card (front and back) will save time at check-in.

License / ID Card

Insurance Front

Insurance Back

Acknowledgement and Authorization to Test:

I acknowledge that I have answered these questions truthfully to the best of my knowledge.

I additionally provide consent for testing and reporting of results by electronic and telephonic means, including email and text messages which may incur a cost by my carrier (reply STOP to cancel). I further consent as a parent or legal guardian to minors that I may have registered. If this registration was organized by my doctor, health care facility, school, place of residence, airline, or employer, I additionally provide consent to share my test results with my related entity's authorized health professionals to facilitate contact tracing and safety measures.

BioVision Group COVID-19 Test Registration

Registration Declined

Registration Confirmed

Cancellation Confirmation

Registration Cancelled