(678) 821-2401
2620 Old Winder Highway, Ste 300, Braselton, GA 30517

COVID Testing Registration Form

STEP 1

Get cost and details. All details are available on our website, including the cost for uninsured.

If you are not sure your insurance carrier covers COVID testing, please visit their website or contact them directly.

STEP 2

Complete the form. This will take approximately 10 minutes. DO NOT close your browser until you are finished and have pressed the SEND button.

STEP 3

Wait for Our Call. We will contact you approximately 45 minutes before your turn to be tested.

In the meantime, make sure you have your photo ID and insurance card ready to go.

When you come into our office, please wear a mask.

STEP 4

Wait for results. Please DO NOT CALL for your results. Our team will call you once the results are back. If you were tested 5 or more days ago, and you need to reach us, please send an email to TestResults@BraseltonUrgentCare.com.

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Personal Data and Contact Information

[/vc_column_text][/vc_column][/vc_row][vc_row css=".vc_custom_1594920695749{padding-top: 5% !important;padding-bottom: 5% !important;}"][vc_column][vc_row_inner][vc_column_inner width="2/3"][vc_column_text]

DO NOT close your browser until you have completed and submitted your form.

NOTE: All fields marked with * are required.[/vc_column_text][/vc_column_inner][vc_column_inner width="1/3"][vc_button title="CLICK HERE FOR A PRINTABLE VERSION" target="_blank" href="https://www.braseltonurgentcare.com/wp-content/uploads/2020/07/Braselton-Urgent-Care-COVID-19-Intake-1.pdf"][/vc_column_inner][/vc_row_inner][vc_row_inner content_placement="top" css=".vc_custom_1596045891367{padding-top: 5% !important;padding-bottom: 3% !important;}"][vc_column_inner][vc_column_text css=".vc_custom_1596048478506{margin-top: 0px !important;padding-top: 0px !important;}"]

START HERE: I agree to have my personal data transmitted via email to Braselton Urgent Care.*  (A copy will also be sent to your email address.)

[/vc_column_text][vc_cf7_elements]Yes[/vc_cf7_elements][/vc_column_inner][/vc_row_inner][vc_row_inner][vc_column_inner width="1/4"][vc_cf7_elements label="First Name*"][/vc_cf7_elements][/vc_column_inner][vc_column_inner width="1/4"][vc_cf7_elements label="Last Name*"][/vc_cf7_elements][/vc_column_inner][vc_column_inner width="1/4"][vc_cf7_elements label="DOB*"][/vc_cf7_elements][/vc_column_inner][vc_column_inner width="1/4"][vc_cf7_elements label="Gender*"]MaleFemale[/vc_cf7_elements][/vc_column_inner][/vc_row_inner][/vc_column][/vc_row][vc_row][vc_column width="1/2"][vc_cf7_elements label="Street Address*"][/vc_cf7_elements][/vc_column][vc_column width="1/6"][vc_cf7_elements label="City*"][/vc_cf7_elements][/vc_column][vc_column width="1/6"][vc_cf7_elements label="State*"][/vc_cf7_elements][/vc_column][vc_column width="1/6"][vc_cf7_elements label="Zip*"][/vc_cf7_elements][/vc_column][/vc_row][vc_row][vc_column width="1/3"][vc_cf7_elements label="Social Security Number*"][/vc_cf7_elements][/vc_column][vc_column width="1/3"][vc_cf7_elements label="Phone*"][/vc_cf7_elements][/vc_column][vc_column width="1/3"][vc_cf7_elements label="Alternate Phone"][/vc_cf7_elements][/vc_column][/vc_row][vc_row][vc_column width="1/3"][vc_cf7_elements label="Email Address*"][/vc_cf7_elements][/vc_column][vc_column width="1/3"][/vc_column][vc_column width="1/3"][/vc_column][/vc_row][vc_section full_width="stretch_row" css=".vc_custom_1594921262887{padding-top: 5% !important;padding-bottom: 5% !important;background-color: #f2f2f2 !important;}"][vc_row][vc_column][vc_column_text]

Employment

[/vc_column_text][/vc_column][/vc_row][vc_row css=".vc_custom_1594921217037{padding-top: 5% !important;}"][vc_column width="1/3"][vc_cf7_elements label="Occupation"][/vc_cf7_elements][/vc_column][vc_column width="1/3"][vc_cf7_elements label="Employer"][/vc_cf7_elements][/vc_column][vc_column width="1/3"][vc_cf7_elements label="Employer Phone"][/vc_cf7_elements][/vc_column][/vc_row][/vc_section][vc_row css=".vc_custom_1594920695749{padding-top: 5% !important;padding-bottom: 5% !important;}"][vc_column][vc_column_text]

Authorized Contact*

[/vc_column_text][/vc_column][/vc_row][vc_row][vc_column width="1/2"][vc_column_text]Due to HIPAA regulations, we are required to have the name of the person we are authorized to discuss your healthcare issues, in the event of a critical matter or
emergency. (For patients over 18)[/vc_column_text][/vc_column][vc_column width="1/2"][vc_cf7_elements]AgreeDisagree[/vc_cf7_elements][/vc_column][/vc_row][vc_row css=".vc_custom_1594921229775{padding-top: 5% !important;}"][vc_column width="1/3"][vc_cf7_elements label="Authorized Name"][/vc_cf7_elements][/vc_column][vc_column width="1/3"][vc_cf7_elements label="Phone Number"][/vc_cf7_elements][/vc_column][vc_column width="1/3"][vc_cf7_elements label="Relationship"][/vc_cf7_elements][/vc_column][/vc_row][vc_section full_width="stretch_row" css=".vc_custom_1594921262887{padding-top: 5% !important;padding-bottom: 5% !important;background-color: #f2f2f2 !important;}"][vc_row][vc_column][vc_column_text]

Insurance Information

[/vc_column_text][/vc_column][/vc_row][vc_row css=".vc_custom_1594921217037{padding-top: 5% !important;}"][vc_column width="1/3"][vc_cf7_elements label="Primary Insurance Carrier"][/vc_cf7_elements][/vc_column][vc_column width="1/3"][vc_cf7_elements label="Subscriber's Name"][/vc_cf7_elements][/vc_column][vc_column width="1/3"][vc_cf7_elements label="Subscriber's Date of Birth"][/vc_cf7_elements][/vc_column][/vc_row][vc_row][vc_column width="1/2"][vc_cf7_elements label="Policy Number"][/vc_cf7_elements][/vc_column][vc_column width="1/2"][vc_cf7_elements label="Group Number"][/vc_cf7_elements][/vc_column][/vc_row][vc_row][vc_column width="1/4"][vc_cf7_elements label="Relationship to Patient"][/vc_cf7_elements][/vc_column][vc_column width="1/4"][vc_cf7_elements label="Social Security Number"][/vc_cf7_elements][/vc_column][vc_column width="1/4"][vc_cf7_elements label="Is this person a patient here?"]YesNo[/vc_cf7_elements][/vc_column][vc_column width="1/4"][vc_cf7_elements label="Gender"]MaleFemale[/vc_cf7_elements][/vc_column][/vc_row][vc_row][vc_column][vc_column_text]


[/vc_column_text][/vc_column][/vc_row][vc_row css=".vc_custom_1594921217037{padding-top: 5% !important;}"][vc_column width="1/3"][vc_cf7_elements label="Secondary Insurance Carrier"][/vc_cf7_elements][/vc_column][vc_column width="1/3"][vc_cf7_elements label="Subscriber's Name"][/vc_cf7_elements][/vc_column][vc_column width="1/3"][vc_cf7_elements label="Subscriber's Date of Birth"][/vc_cf7_elements][/vc_column][/vc_row][vc_row][vc_column width="1/2"][vc_cf7_elements label="Policy Number"][/vc_cf7_elements][/vc_column][vc_column width="1/2"][vc_cf7_elements label="Group Number"][/vc_cf7_elements][/vc_column][/vc_row][vc_row][vc_column width="1/4"][vc_cf7_elements label="Relationship to Patient"][/vc_cf7_elements][/vc_column][vc_column width="1/4"][vc_cf7_elements label="Social Security Number"][/vc_cf7_elements][/vc_column][vc_column width="1/4"][vc_cf7_elements label="Is this person a patient here?"]YesNo[/vc_cf7_elements][/vc_column][vc_column width="1/4"][vc_cf7_elements label="Gender"]MaleFemale[/vc_cf7_elements][/vc_column][/vc_row][vc_row][vc_column][vc_cf7_elements label="Is this visit due to a work related injury?*"]yesno[/vc_cf7_elements][/vc_column][/vc_row][vc_row css=".vc_custom_1594930907737{padding-top: 5% !important;padding-bottom: 5% !important;}"][vc_column width="2/3"][vc_column_text]The above information is true to the best of my knowledge. I authorize my insurance benefits be paid directly to the physician. I understand that I am financially responsible for any balance. I also authorize Braselton Urgent Care or insurance company to release any information required to process my claims.[/vc_column_text][/vc_column][vc_column width="1/3"][vc_cf7_elements label="Signature (Legal and Binding)*"][/vc_cf7_elements][/vc_column][/vc_row][vc_row][vc_column][vc_cf7_elements label="Guarantor (responsible for bill)*"][/vc_cf7_elements][/vc_column][/vc_row][/vc_section][vc_section][vc_row][vc_column][vc_column_text]

In Case of Emergency

[/vc_column_text][/vc_column][/vc_row][vc_row css=".vc_custom_1595259073388{padding-top: 3% !important;}"][vc_column width="1/2"][vc_cf7_elements label="Name of local friend or relative, not living at the same address*"][/vc_cf7_elements][/vc_column][vc_column width="1/2"][vc_cf7_elements label="Relationship to Patient*"][/vc_cf7_elements][/vc_column][/vc_row][vc_row][vc_column width="1/2"][vc_cf7_elements label="Phone*"][/vc_cf7_elements][/vc_column][vc_column width="1/2"][vc_cf7_elements label="Alternate Phone"][/vc_cf7_elements][/vc_column][/vc_row][/vc_section][vc_section full_width="stretch_row" css=".vc_custom_1594931463643{padding-top: 5% !important;background-color: #f2f2f2 !important;}"][vc_row][vc_column][vc_column_text]

Health History

[/vc_column_text][/vc_column][/vc_row][vc_row css=".vc_custom_1595259084500{padding-top: 3% !important;}"][vc_column width="1/2"][vc_cf7_elements label="Pharmacy*"][/vc_cf7_elements][/vc_column][vc_column width="1/2"][vc_cf7_elements label="Pharmacy Address"][/vc_cf7_elements][/vc_column][/vc_row][vc_row][vc_column width="1/3"][vc_cf7_elements label="Medication"][/vc_cf7_elements][/vc_column][vc_column width="1/3"][vc_cf7_elements label="Dosage"][/vc_cf7_elements][/vc_column][vc_column width="1/3"][vc_cf7_elements label="Reason"][/vc_cf7_elements][/vc_column][/vc_row][vc_row][vc_column width="1/3"][vc_cf7_elements label="Medication"][/vc_cf7_elements][/vc_column][vc_column width="1/3"][vc_cf7_elements label="Dosage"][/vc_cf7_elements][/vc_column][vc_column width="1/3"][vc_cf7_elements label="Reason"][/vc_cf7_elements][/vc_column][/vc_row][vc_row][vc_column width="1/3"][vc_cf7_elements label="Medication"][/vc_cf7_elements][/vc_column][vc_column width="1/3"][vc_cf7_elements label="Dosage"][/vc_cf7_elements][/vc_column][vc_column width="1/3"][vc_cf7_elements label="Reason"][/vc_cf7_elements][/vc_column][/vc_row][vc_row][vc_column width="1/3"][vc_cf7_elements label="Medication"][/vc_cf7_elements][/vc_column][vc_column width="1/3"][vc_cf7_elements label="Dosage"][/vc_cf7_elements][/vc_column][vc_column width="1/3"][vc_cf7_elements label="Reason"][/vc_cf7_elements][/vc_column][/vc_row][vc_row][vc_column width="1/3"][vc_cf7_elements label="Medication"][/vc_cf7_elements][/vc_column][vc_column width="1/3"][vc_cf7_elements label="Dosage"][/vc_cf7_elements][/vc_column][vc_column width="1/3"][vc_cf7_elements label="Reason"][/vc_cf7_elements][/vc_column][/vc_row][vc_row][vc_column width="1/3"][vc_cf7_elements label="Medication"][/vc_cf7_elements][/vc_column][vc_column width="1/3"][vc_cf7_elements label="Dosage"][/vc_cf7_elements][/vc_column][vc_column width="1/3"][vc_cf7_elements label="Reason"][/vc_cf7_elements][/vc_column][/vc_row][vc_row][vc_column width="1/2"][vc_cf7_elements label="Please list any drug allergies."][/vc_cf7_elements][/vc_column][vc_column width="1/2"][vc_cf7_elements label="Reason for visit.*"][/vc_cf7_elements][/vc_column][/vc_row][vc_row][vc_column css=".vc_custom_1594932250854{margin-top: 5% !important;}"][vc_column_text]

Please indicate any health conditions for which you are currently being treated or have ever been treated.

[/vc_column_text][/vc_column][/vc_row][vc_row css=".vc_custom_1595259099854{padding-top: 3% !important;}"][vc_column width="1/2"][vc_cf7_elements][/vc_cf7_elements][/vc_column][vc_column width="1/2"][vc_cf7_elements][/vc_cf7_elements][/vc_column][/vc_row][vc_row][vc_column css=".vc_custom_1594932256717{margin-top: 5% !important;}"][vc_column_text]

Please list any surgeries, hospitalization and/or serious injuries.

[/vc_column_text][/vc_column][/vc_row][vc_row css=".vc_custom_1595259106343{padding-top: 3% !important;}"][vc_column width="2/3"][vc_cf7_elements label="Reason/Type"][/vc_cf7_elements][/vc_column][vc_column width="1/3"][vc_cf7_elements label="Date"][/vc_cf7_elements][/vc_column][/vc_row][vc_row][vc_column width="2/3"][vc_cf7_elements label="Reason/Type"][/vc_cf7_elements][/vc_column][vc_column width="1/3"][vc_cf7_elements label="Date"][/vc_cf7_elements][/vc_column][/vc_row][vc_row css=".vc_custom_1594932422713{padding-top: 5% !important;}"][vc_column width="1/3"][vc_cf7_elements label="Is there any chance you are pregnant?*"]YesNo[/vc_cf7_elements][/vc_column][vc_column width="1/3"][vc_cf7_elements label="Are you a smoker?*"]YesNo[/vc_cf7_elements][vc_cf7_elements label="If yes, how many packs per day?"][/vc_cf7_elements][/vc_column][vc_column width="1/3"][vc_cf7_elements label="Do you drink alcohol?*"]DailySociallyNever[/vc_cf7_elements][/vc_column][/vc_row][/vc_section][vc_section css=".vc_custom_1594932738849{padding-top: 5% !important;padding-bottom: 5% !important;}"][vc_row][vc_column][vc_column_text]

Patient Authorization

Consent to Treat

I hereby authorize Braselton Urgent Care to render medical care to me during my office visit and to fulfill the orders of my physicians; including consultants, associates and assistants of the physician’s choice.

Financial Authorization

I am financially responsible for the services provided which are to be paid on the day services are rendered. I further acknowledge that I am the owner/dependent of the insurance policy and that the insurance contract is between myself/policyholder and the insurance carrier. Braselton Urgent Care has no leverage to obtain payment from my insurance carrier. As such, Braselton Urgent Care will appropriately bill my insurance carrier however I will be responsible for all unpaid services due to copay, deductibles, or rejected claims.

Braselton Urgent Care will attempt to verify insurance coverage at the time of service. Benefit and eligibility information obtained may be inaccurate or incomplete and only the final Explanation of Benefits (EOB) sent from the insurance carrier will stand as the final statement of monies owed. I will be billed (or credited) for any outstanding balances (or overcharges) whereupon I am obliged to make payment within 30 days. After 60, past due amounts may be charged to my credit card kept on file with Braselton Urgent Care. I realize that failure to keep this account current may result in Braselton Urgent Care being unable to provide continuing medical services.

Consent to Use and Release of Medical Information

I authorize Braselton Urgent Care to release medical information pertaining to my diagnosis and/or treatment, laboratory results, medical history, treatment, or any other such related information to:

  • My insurance company(ies) or its designated representatives.
  • Any person(s) or entities financially responsible for my care or treatment.
  • Representatives or local, state, or feral agencies in accordance with law.
  • Employees or representatives for investigation and defense of any claim or cause of action, actual or potential which may be asserted against Braselton Urgent Care or its employees.

I have been provided with a Notice of Privacy Practices that provides a more complete description or information uses disclosures. I understand that I have the right to review the notice prior to signing this consent.  I understand that the organization reserves the right to change their notice and practices and prior to implementation will mail copy of the revised notice to the address I’ve provided. I understand that I have the right to object to the use of my health information for directory purposes. I understand that I have the right to request restrictions as to how my health information may be used or disclosed to carry out treatment, payment or healthcare operations and that the organization is not required to agree with the restrictions requested. I understand I may revoke this consent in writing, except to the extent that the organization has already taken action in reliance thereon.[/vc_column_text][/vc_column][/vc_row][vc_row css=".vc_custom_1595259117920{padding-top: 3% !important;}"][vc_column width="2/3"][vc_cf7_elements label="Signature of Patient/Legal Representative*"][/vc_cf7_elements][/vc_column][vc_column width="1/3"][vc_cf7_elements label="Date*"][/vc_cf7_elements][/vc_column][/vc_row][/vc_section][vc_section full_width="stretch_row" css=".vc_custom_1594933670256{padding-top: 5% !important;padding-bottom: 5% !important;background-color: #f2f2f2 !important;}"][vc_row][vc_column][vc_column_text]

Patient Consent for Disclosure of Protected Health Information

I have the right to review the Notice of Privacy Practices prior to signing this consent. Braselton Urgent Care reserves the right to revise its Notice of Privacy Practices at any time.

I acknowledge and agree that Braselton Urgent Care and/or vendor including billing and/or collection companies may contact me on the numbers listed below. I further agree that I may be contacted by use of an Automated Telephone Dialing System (ATDS) or prerecorded message. With this consent, Braselton Urgent Care may share my Personal health information (PHI) in the following methods:[/vc_column_text][/vc_column][/vc_row][vc_row css=".vc_custom_1595259131249{padding-top: 3% !important;}"][vc_column width="1/3"][vc_cf7_elements label="Leave a message on home phone:*"][/vc_cf7_elements][/vc_column][vc_column width="1/3"][vc_cf7_elements label="Leave a message on cell phone:*"][/vc_cf7_elements][/vc_column][vc_column width="1/3"][vc_cf7_elements label="Send an email:*"][/vc_cf7_elements][/vc_column][/vc_row][vc_row css=".vc_custom_1594933745175{padding-top: 3% !important;}"][vc_column][vc_column_text]I authorize Braselton Urgent Care to release/disclose my PHI including lab and test results, diagnosis and treatments to the following individuals:[/vc_column_text][/vc_column][/vc_row][vc_row css=".vc_custom_1595259143164{padding-top: 3% !important;}"][vc_column width="1/3"][vc_cf7_elements label="Name"][/vc_cf7_elements][/vc_column][vc_column width="1/3"][vc_cf7_elements label="Relationship"][/vc_cf7_elements][/vc_column][vc_column width="1/3"][vc_cf7_elements label="Phone:"][/vc_cf7_elements][/vc_column][/vc_row][vc_row][vc_column width="1/3"][vc_cf7_elements label="Name"][/vc_cf7_elements][/vc_column][vc_column width="1/3"][vc_cf7_elements label="Relationship"][/vc_cf7_elements][/vc_column][vc_column width="1/3"][vc_cf7_elements label="Phone:"][/vc_cf7_elements][/vc_column][/vc_row][vc_row css=".vc_custom_1594933760818{padding-top: 3% !important;}"][vc_column][vc_column_text]I may revoke my consent in writing except to the extent that the practice has already made disclosures in reliance upon my prior consent[/vc_column_text][/vc_column][/vc_row][vc_row css=".vc_custom_1595259149525{padding-top: 3% !important;}"][vc_column width="1/2"][vc_cf7_elements label="Signature of Patient or Legal Guardian*"][/vc_cf7_elements][/vc_column][vc_column width="1/2"][vc_cf7_elements label="Date*"][/vc_cf7_elements][/vc_column][/vc_row][/vc_section][vc_row][vc_column][vc_cf7_elements]

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