Camp (new account) - A2Z Diagnostics

Current Date

Submitting Representative

Camp Name *

WiFi Internet Connection at Test Site

WiFi
Ethernet
None

Will A2Z be supplying swabber

Yes
No

Will QR codes need to be created for Camp Registration

Yes
No

Number of Tests Needed for Camp

Date Of Test

Hours Of Testing

# of PCR

# of Antigen

# of Rapid PCR (Accula)

Camp Location & Contact Information

Address Line 1

Address Line 2

City

State

Zip Code

Main Phone

Cell Phone

Camp Coordinator

Email *

Patient Results

Will Camp Coordinator Receive all Patient Results?

Yes
No

If Yes enter Camp Coordinator Results?

Would you like patients to receive results via Test or Email

Yes
No

Payment

Insurance

Yes
No

Client bill (Camp to be Billed & Pay for testing for Uninsured/Foreign Individuals)

Yes
No

If yes, what is the amount to be paid Antigen Test?

Enter the amount for each: Antigen $, PCR $, Rapid PCR $

Amount to be paid PCR Test?

Amount to be paid Rapid PCR Test?

Patient Pay (Uninsured/Foreign Individuals to Pay for testing) *

Yes
No

* This Option REQUIRES A2Z approval

If yes, what is the amount to be paid

Enter the amount for each: Antigen $, PCR $, Rapid PCR $

Camp to Pay for A2Z swabber

Yes
No

Is a Contract Required?

Yes
No

Comments

Disclaimer:
A2Z Diagnostics will not test individuals that are not registered, and payment options are selected