Rapid Covid Testing

Occupational Care Services Intake Form & Registration

Please complete the following form to begin registering for Rapid Covid Testing.

Rapid Nasal Swab $75 credit / $70 cash

Rapid Blood Serum $50

Payment for services will be collected during your visit.

Employee/Patient Full Legal Name

Home Address

Last Four Digits of SSN

Phone

Birthday

Sex

Male

Female

Employer/Company

Are you experiencing any flu-like symptoms, or feeling sick today?

Yes

Have you or a family member traveled internationally within the past 3 months?

Yes

Have you/a family member been in contact with someone who has a confirmed case of COVID-19?

Yes

I authorize OCS, and its associates to perform services and/or tests related to and authorized by me as an individual, employer, school, court or other authorizing agency. I authorize the release of any records, or other information to my employer, insurance carrier, or any other agent for whom these services are being authorized. I understand if services are found not authorized I will be responsible for payment of services related to this service. I give my consent and permission to OCS to obtain a specimen to be tested for SARS-Cov-2 IgM. I understand and authorize the result of this testing will be disclosed to the employer requesting the services. Disclosure and use of results, information or any other private information will be limited in accordance with applicable laws covering confidentiality of records. I understand I have the right to refuse services and the employer authorizing and requesting such services can and will be notified. I understand that OCS and its associates retain the right to refuse services to any individual not complying with State or Federal Laws and Regulation. I understand that OCS is not responsible for employment outcomes based on drug or alcohol testing or any other screening test.

Your Signature