Book Now - Express Test

Schedule Online or Call Now to Book

Email(Required)

This is for communication as well as where your lab results will be sent.

Phone(Required)

So our testers can communicate when they are on their way.

Address(Required)

Please include street address (If you have an Apt # please post in Address Line 2)

Street Address Address Line 2 City State ZIP Code

Notes for Tester

Special notes for your tester such as Gate Code, Apt # etc. Anything our tester needs to know prior to arrival?

Appointment Date(Required)

PLEASE NOTE: At this time ExpressTest MHS is no longer offering at-home services on Saturday or Sunday. We apologize for this inconvenience.

Appointment Time(Required)

Number of People Getting Tested(Required)

Primary Patient First Name(Required)

Primary Patient Last Name(Required)

Primary Patient DOB(Required)

Primary Patient Gender(Required)

Please upload the following now to save time during your appointment.

Insurance Card - Front
Insurance Card - Back
Drivers License

For those uninsured you can fill out a form your tester will provide confirming your uninsured status.

Upload Documents

Drop files here or

Accepted file types: jpg, gif, png, pdf, Max. file size: 512 MB.

Insurance Status(Required)

If insured, please make sure to upload images of your insurance card. Front and back. For uninsured, please confirm the below. Si es asegurado, por favor asegúrese cargar las imágenes de su tarjeta de seguro. Frente y reverso. Para no asegurados, por favor confirmar lo siguiente. PLEASE NOTE: AS OF THIS NOTICE CONGRESS HAS NOT APPROVED ADDITIONAL FUNDING FOR COVID TESTING. THIS MEANS THAT UNINSURED TESTING WILL NOT BE COVERED. IN ORDER TO BOOK AND RECIEVE A COVID TEST YOU MUST PROVIDE VALID US INSURANCE COVERAGE . AS AN ALTERNATIVE WE WILL BE OFFERING A DIRECT PAY OPTION. COST PER DIRECT PAY WILL BE $150

Insured

Uninsured

Uninsured Confirmation By confirming and proceeding with your submission you are confirming that you are not covered or enrolled under any private, individual (non-group or COBRA) or group (employer or other organization-sponsored) health insurance plan, any federal health care program (including but not limited to Medicare, Medicaid or TRICARE), nor am I covered under the health insurance of a spouse or parent. Al confirmar y proceder con su sometimiento está usted confirmando que no está cubierto o afiliado a ningún plan de seguro de salud privado, individual (no-grupal o COBRA), programa de cuidado de salud federal (incluyendo pero no limitado a Medicare, Medicaid o TRICARE), y que tampoco está cubierto bajo algún seguro de salud de un conyugue o pariente.

Uninsured Confirmation(Required)

Confirmed

Positive Contact Past 14 Days?(Required)

Have you been in contact with anyone in the past (14) days who may be COVID Positive ? ¿Ha estado en contacto en los últimos catorce (14) días con alguien que podría ser COVID Positivo?

Yes/Si

How many days since last contact?

Exposure(Required)

Have you been out in public to any of the following locations in the past 14 days? ¿Ha estado en público en cualquiera de estos lugares en los últimos 14 días

Grocery Store / Abasto (Z20.822)

Supermarket / Supermercado (Z20.822)

Gas Station / Gasolinera (Z20.822)

Restaurant / Restaurente (Z20.822)

School / Escuela (Z20.822)

House of Worship / Case de la adoracion (Z20.822)

Airport / Aeropuerto (Z20.822)

Uber / Public Transport Transporte Publico (Z20.822)

Work -Office / Trabajo (Z20.822)

Pregnant(Required)

YES / SI (Z34.90)

Smoker(Required)

YES / SI (Z72.0)

Symptoms(Required)

Are you currently experiencing or experienced in the past 14 day any of following symptoms?: ¿Tiena actualmente o ha experimentado en los ultimos 14 duas alguno de los siguientes sintomas?

Medical History / Pre-Existing Conditions(Required)

Do you have a history of any of the following, select all that apply. ¿Tiene un historial de cualquiera de los siguientes?

Questionnaire filled in by(Required)

Patient

Guardian

By signing below you are confirming the information you will provide to be correct and truthful to the best of your knowledge. You are authorizing the information to be submitted for review by the ordering physician. You are authorizing Myhealthsight LLC and it's physician and lab partners to bill your insurance for the services provided and rendered and may be shared to assist for the purpose of billing and processing. All information provided will be used to assist with the billing for provided services.

Please acknowledge by clicking the checkbox below.(Required)

I acknowledge and consent

Signature(Required)

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