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Spector Scientific Lab 160 SW 12th Ave. Suite 103B Deerfield Beach, FL 33442

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Call 561-507-0522 Ext. 101
or Use PayPal
Please include your account number in the comment section when paying with PayPal

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REGISTRATION FOR THE COVID-19 TEST

First Name

Last Name

Date of Birth

Phone

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Medical insurance

If you do not have medical insurance, it's OK! Billing will be processed through government grant assistance. If you DO have the medical isurance, you MUST fill out the following information, in order to have your COVID screening with no copay.

Do you have medical insurance?YesNo

Insurance Name

Policy ID

For continuation, you should attach the photo or scan of your INSURANCE CARD and GOVERNMENT ID using the left form to upload the picture files, one file per form

Insurance Card

No file chosen

Upload image (Max 8 MB)

Government Id

No file chosen

Upload image (Max 8 MB)

COVID-19 Screening Questionnaire

Your event ID number

Do you suspect that you may have been exposed to the COVID-19 in the past 6 months?YesNo

Have you or any family member, neighbor, co-worker, or anyone you know experienced symptoms of Covid-19 over the last 6 months:

FeversCoughWheezingShortness of breath / Difficulty breathingSore throatChillsPainful swallowingRunny nose / Nasal congestionFeeling unwell / FatiguedNausea / Vomiting / DiarrheaUnexplained loss of appetiteLoss of sense of test or smellMuscle or joint achesHeadachesConjunctivitis (Pink eye)No symptoms at all

Have you travelled outside the United States in the last 6 months?YesNo

Have you had ANY contact with someone who has tested POSITIVE for COVID-19?YesNo

Please, list all your medications

Please, list all your allergies

Do you have an order for COVID test from your primary care doctor?YesNo

Doctor will contact only POSITIVE Covid-19 patients. Results usually take 2-5 days (up to 6 if swabbed on Friday or Saturday). Please allow this time before contacting us. Premature contact will delay resulting as we are all working long hours to get you the fastest results.

Please, provide ELIGIBLE EMAIL ADDRESS if a physical copy of results is REQUIRED for work release:

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