9635 Hillcroft St.

Houston, Texas - 77096

RESULTS IN 6 - 12 HOURS

WALK-INS WELCOME !!

Phone: (713) 242-8653

Email: info@rapiddxlabs.com

Beginning SATURDAY, September 3rd, Rapid Dx will only provide testing to those that are insured OR self-paying. If a patient is uninsured but willing to pay out of pocket, the cost of a COVID-19 test will be $76.98, a FLU-COVID test is $102 and a Respiratory Pathogen Panel (RPP) will be $255.37.

Nurses Signature:

Patient Registration

Details must match your Government ID or Passport/ Los detalles deben coincidir con su identificación governamental o pasaporte

First Name/ Primer Nombre *

Middle Name/ Segundo Nombre

Last Name/ Apellido *

Date of Birth/ Fecha de Nacimiento (mm-dd-yyyy) *

Sex/Gender Sexo/Genero *

Identification Card of the patient or of the patient's legal guardian/ Tarjeta de identificación del paciente o del guardian del paciente *

Phone Number/ Numero de Telefono *

Email Address/ Correo Electronico *

Ethnicity/ Etnicidad *

Race/ Raza *

Street Address/ Direccion *

Address Line 2/ Direccion Alternativa

City/ Ciudad *

State/ Estado *

Zip Code/ Código Postal *

Passport Number/ Numero de Pasaporte (Optional) 🛈

Billing Information

Please fill out the fields below to provide your consent to authorize the lab (Rapid Dx), and those assisting with your test to bill your insurance for the service provided. /Complete los campos a continuación para brindar su consentimiento para autorizar al laboratorio (Rapid Dx) y a quienes lo ayudan con su prueba a facturar a su seguro por el servicio brindado.

Medicare -- Medical (Part B) Coverage/Medicare -- Covertura medica (Parte B) *

YES

NO, I do not have Medicare -- Medical (Part B) Coverage

Private Insurance Coverage/Aseguranza Privada *

Insured/Asegurado(a)

Cash Pay/ Credit Card/Effectivo o Tarjeta de Credito

*** Note: VA Insurance is not accepted. If you have secondary insurance, please provide that as your primary insurance. Otherwise, you will have to self-pay.

*

COVID-19

RPP

FLU-COVID

Insurance Card (Medicare/ Medicaid or private insurance)/Foto de Aseguranza Privada o Medicaid *

Insurance Provider/Nombre de Aseguranza *

Primary Insurance ID#/Numero ID# de Identificación del Plan *

Primary Insurance Group #/Grupo Medico del Plan

Primary Relationship to insured/ Relación del Asegurado(a) *

Do you have secondary insurance? *

Yes

No

Secondary Insurance Provider/Nombre de Aseguranza *

Secondary Insurance ID#/Numero ID# de Identificación del Plan *

Secondary Insurance Group #/Grupo Medico del Plan

Secondary Relationship to insured/ Relación del Asegurado(a) *

By signing this document, I attest that the above mentioned financial information is true and accurate to the best of my knowledge. Rapid Dx Labs may contact me should they experience issues with the indicated payment options or other concerns./Al firmar este documento, acepto la responsabilidad financiera y estoy al tanto de las tarifas de las pruebas. Entiendo que soy responsable de presentar mi propio reclamo de seguro. Como paciente de Medicare, también soy consciente de que soy responsable del pago a Rapid DX LLC. Si Medicare niega el pago. *

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Patient COVID-19 Screening Questionnaire

Representations

First COVID Test? Es su Primer Examen de COVID-19? *

Yes

No

Are you employed in Healthcare?/Esta empleado en un centro de salud? *

Yes

No

Are you currently experiencing, or have you experienced in the past 14 days, any of the following symptoms? (Please take your temperature before you answer this question.) /¿Está experimentando actualmente, o ha experimentado en los últimos 14 días, alguno de los siguientes síntomas? (Tómese la temperatura antes de responder esta pregunta). *

	Yes	No
Fever/ Fiebre	Yes	No
Cough/ Tos	Yes	No
Shortness of breath or difficulty breathing/ Falta de aire o difficultad para respirar	Yes	No
New loss of taste or smell/ Nueva perdida del gusto o olfato	Yes	No
Chills/ Escalofrios	Yes	No
Head or muscle aches/ Dolor de Cabeza o Musculos	Yes	No
Nausea, diarrhea, vomiting (vomito)	Yes	No

In the past 14 days, have you been in close proximity to anyone who was experiencing any of the above symptoms or has experienced any of the above symptoms since your contact?/En los ultimos 14 dias, ha estado en proximidad con alguien que experimento algun simptoma mencionado o esta experimentando algun simptoma mencionado ahora? *

Yes

No

In the past 14 days, have you been in close proximity to anyone who has tested positive for COVID-19?/En los ultimos 14 dias, ha estado cerca de alguien que fue positivo de COVID-19? *

Yes

No

Hospitalized in the last 14 days?Ha sido hospitalizado en los ultimos 14 dias? *

Yes

No

Resident in a congregate care setting (including nursing homes, residential care for intellectual and developmental disabilities, psychiatric treatment facilities, group homes, board and care homes, homeless shelter, foster care or other setting)?/Es residente de alguna situacion de vivir en grupo (como asilo de ancianos, centro de atencion residencial para desabilitaciones intellectuales o de desarollo, centro psiquiatrico, casa de grupo, pensiones y casas de acogida, refugio para indigentes, orfanato, o otro lugar?) *

Yes

No

Pregnant?/Embarazada? *

Yes

No

Traveled in the last 14 days?/Ha viajado en los ultimos 14 dias? *

Yes

No

Completion

I hereby certify that the responses provided are true and accurate to the best of my knowledge./Certifico que la información que he proporcionado anteriormente es exacta a mi leal saber y entender. *

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DATE/FECHA (mm/dd/yyyy) *