COVID-19

Are you at least 18 years or older? *

Pick a date

Please choose one of the available dates.

Pick a time

Please choose one of the available times:

Verify your contact information

For the communication purposes, we will need a reliable contact to confirm your appointment and securely share available results with you.

Please enter a phone number that can receive SMS messages. Text message frequency varies. Message and data rates may apply.

COVID-19 Questionnaire

Have you had any of these symptoms in the past 14 days?*

COVID-19 Questionnaire

COVID-19 Questionnaire

Do you have any high-risk medical conditions?*

COVID-19 Questionnaire

Have you come into contact with any person who has tested positive for COVID-19?*

COVID-19 Questionnaire

Have you recently traveled?*

COVID-19 Questionnaire

Are you a healthcare worker with direct contact with patients?*

COVID-19 Questionnaire

Are you in close contact with anyone over age 65, with an impaired immune system, with diabetes, liver disease, lung disease, or who is pregnant?*

Are you employed in one of the following categories?*

Your Demographic Information

What is your sex and race?

Why are we asking for this?

Your Contact Details

Your Address Details

Are you a Federal Employee?*

Your Insurance Details

Do you have health insurance? There is no cost to you either way.*

We may bill insurance, but by law the insurance company may not charge you any co-pay, deductible, or out-of-pocket expense for the COVID-19 related visit.

Why are we asking for this information?

Your health insurance information

If you don't submit a valid insurance card, the on-site staff may still ask to review your insurance card in-person.

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I attest that I don't have employer-sponsered or individual healthcare coverage, Medicare, Medicaid and that no other payer will reimburse for COVID-19 testing from 360clinic.

Consent Form

I have read the contents of this form in its entirety and voluntarily consent to undergo diagnostic testing for COVID-19.

AGREEMENT FOR SELF-ISOLATION

The local health jurisdiction has determined that if you are under suspicion for having COVID-19 due to symptoms and testing requests, it is necessary to be placed in isolation in order to prevent the transmission of this infection. It is important for you to comply with this Isolation Agreement in order to protect the public’s health.

Your initial confirms that you consent to COVID-19 testing, and, if you have any of the symptoms, you will isolate yourself from any other people until you receive a negative test result.

Please confirm your info and book your appointment.

Your appointment is confirmed.

Confirmation number

Please remember to bring your ID and your confirmation number to your appointment

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