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PCR COVID-19 Testing Form (Onsite)

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On-Site Location
Choose your location:
Please select your tests from the following options:
More than one test may be selected.
Single Testing Prices

Covid-19 PCR Test - $200
Covid Test - $60
Flu A/B Test - $60
RSV/hMPV Test - $60
Strep Test (tests for Strep A, C G) - $60
If you need a Covid-19 test, please select one below:
- Covid-19 PCR Test
- Covid-19 Test
Other Available Tests
- Flu A/B Test
- RSV/hMPV Test
- Strep Test (tests for Strep A, C, G)
All testing services selected can be paid for at your appointment.

General Information
Name*
First Middle Initial Last
Date of Birth*
Month
Day
Year
Phone*
Race*
- American Indian or Alaska Native
- Asian
- Black or African American
- Native Hawaiian or Other Pacific Islander
- White
- Other
- Unknown
Ethnicity*
- Hispanic
- Non-Hispanic
- Unknown
Sex*
- Male
- Female
- Other
- Unknown
- Ambiguous
Address*
City*
State*
Zip Code*
County*
Email*
We require an email address so we may send you information regarding your testing.

Exposure
In the past 14 days, have you had known or suspected exposure to the SARS-Cov-2 virus or a COVID-19 patient?*
- Yes
- No
“Those with major health insurance should check with their insurance provider for coverage eligibility when testing without experiencing symptoms and recent exposure to Covid-19. Test costs not covered by a patients’ insurance or providing inactive/inaccurate health insurance information will result in a bill for testing performed.”

Symptoms Questionnaire
Are you experiencing any symptoms?*
- Yes
- No
Fever > 100.4 F° (38 C°)*
- Yes
- No
New loss of taste or smell*
- Yes
- No
Chills*
- Yes
- No
Muscle or body aches*
- Yes
- No
Congestion or runny nose*
- Yes
- No
Sore Throat*
- Yes
- No
Cough*
- Yes
- No
Shortness of breath or difficulty breathing*
- Yes
- No
Nausea or vomiting*
- Yes
- No
Headache*
- Yes
- No
Abdominal pain*
- Yes
- No
Diarrhea*
- Yes
- No
Fatigue*
- Yes
- No
Any other symptoms not listed above*
- Yes
- No
Other symptoms, please specify:*
When did the symptoms begin?
MM slash DD slash YYYY
- I don't know when the symptoms began

Medical Conditions
Asthma or chronic lung disease*
- Yes
- No
Cirrhosis of the liver*
- Yes
- No
Serious heart condition, such as Congestive Heart Failure*
- Yes
- No
Diabetes*
- Yes
- No
Kidney failure or end stage renal disease*
- Yes
- No
Conditions that result in a weakened immune system, including cancer treatment*
- Yes
- No
Extreme obesity*
- Yes
- No
Diseases or conditions that make it harder to cough*
- Yes
- No
Any other medical conditions not listed above*
- Yes
- No
Other medical conditions, please specify:*

Additional Questions
Are you currently pregnant?*
- Yes
- No
Do you work in healthcare?*
- Yes
- No
Have you been tested previously for COVID-19?*
- Yes
- No
Do you work in a special setting where the risk of COVID-19 transmission may be high?*
- Yes
- No

Insurance Verification
Do you have health insurance?*
- Yes
- No
“Government funded Covid-19 testing for the un-insured ended on 3/22/22. Our PCR Testing will cost $130 (cash or card) for those without health insurance. Test costs not covered by a patients’ insurance or providing inactive/inaccurate health insurance information will result in a bill for testing performed.”
Please Provide Your Social Security Number.*
Needed for uninsured claim submission. Per the HRSA announcement on 3/16/22, government funded Covid-19 testing claim submissions ends for the uninsured on 3/22/22. Effective 3/18/22, Advanced Laboratory Services' PCR Testing will cost $130 (cash or card) for those without insurance. Providing inactive or inaccurate health insurance information will result in a bill for testing performed.
Are you the insurance policyholder?*
- Yes
- No
What is your Insurance Company?*
What is your Policy #?*
What is your Group #?*
Please provide the full name of the policyholder.
First Name*
Middle Initial*
Last Name*
What is the Date of Birth of the policyholder or responsible party?*
Month
Day
Year
What is the Insurance Company of the policyholder or responsible party?*
What is the Policy # of the policyholder or responsible party?*
What is the Group # of the policyholder or responsible party?*
What is your relationship to the insured?*
- Spouse
- Dependent
Please bring physical insurance card and Driver's License or other valid photo identification.

Consent
Consent Policy*
The information provided is 100% accurate and I provide consent to Advanced Laboratory Services to receive my personal information. I allow Advanced Laboratory Services to contact me about my information and Covid-19 testing needs.

Advanced Laboratory Services is committed to the privacy and security of the protected health information provided. The services we provide inherently require the limited and responsible sharing of this information specifically to departments of public health for their operational and planning purposes.
Yes, I consent.
Updated Uninsured Testing Policy*
Per the HRSA announcement on 3/16/22, government funded Covid-19 testing claim submissions ends for the uninsured on 3/22/22. Effective 3/18/22, Advanced Laboratory Services' PCR Testing will cost $130 (cash or card) for those without insurance. I understand that providing inactive or inaccurate health insurance information will result in a bill for testing performed.
Yes, I agree to pay $130 for my uninsured COVID-19 Testing.
Exposure Policy*
Those with major health insurance should check with their insurance provider for coverage eligibility when testing without experiencing symptoms and recent exposure to Covid-19. Test costs not covered by a patients’ insurance or providing inactive/inaccurate health insurance information will result in a bill for testing performed.
Yes.

Phone:
903-487-0598

Address:
500 E Peyton St, Suite 300 Sherman, TX 75090

Hours:
Mon. - Fri. 8:30am – 4:30pm
Sat. Closed
Sun. Closed

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