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Service Request Form

Onsite COVID-19
Services Request Form

Service Request Form


    IgG Anti body Test Onlyq-PCR Test OnlyBoth IgG and q-PCTVaccine Waiting List


    YesNo


    IndoorsOutdoors


    YesNo


    Online SchedulerInternal Sign-Up Sheet

    Now that you filled out this form don't forget to download the Consent Form.

    Please download this CONSENT FORM, print it, fill it out and bring it the day of your appointment.

    CONSENT FORM

    Day of Testing Instructions

    • Please have patient bring consent form, photocopy of their health insurance card (front and back) and photocopy of government ID (driver’s license, ID Card, etc.)
    • If employees or family members are paying have them bring exact cash or check made out to “The Wellness Group”. On the top of the Consent form, please write “Paid in Cash or Check”.
    • Nurse will collect Consent forms and photocopies to include with blood sample.
    • Patients do NOT need to fast.
    • Patients should be hydrated day of event; this makes drawing easier.
    • Please have all patients wear a short sleeve shirt.
    • For our sign in area we will need one table, one chair and one small trash can.
    • Each nurse station will need one table, one small trash can and two chairs (one for the nurse and one for patient).
    • Keep all tables six feet from each other.
    • Please have appointment line taped off every six feet when patients queue.
    • One nurse can draw 10 people per hour, we can add more staff to accommodate your time frame.
    • Please provide juice (orange and apple) and cookies for your employees in case they need it.

    Disclaimer

    The Abbott RealTime SARS-CoV-2 has been authorized by the FDA under an Emergency Use Authorization for use by authorized laboratories. The test has been authorized only for the detection of nucleic acid from SARS-CoV-2, not for any other viruses or pathogens.

    Testing positive for the Covid IgG antibody does not guarantee immunity at this time but as more tests are received, we hope to be able to confirm immunity in the future.
    Because this is a blood draw which is tested in a laboratory, the results are 99.9% accurate.

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    Want more information?

    We are Here To Assist You

    Please fill out this form to the best of your knowledge.

    The more information you provide the better we will be able to assist you.

    Thank you.

      Contact Information: (Required)

      People Growers Contact (If you have one)

      Company Name: *

      Name: *

      Title:

      Company Address *

      City *

      State *

      Zip *

      Phone number: *

      EXT:

      Email Address: *

      Number of employees

      Local: *

      National:

      I am interested in (Check all that apply)

      Health & Wellness FairSports & Fitness FestivalOnsite Biometric ScreeningOpen Enrollment ExpoFlu VaccinationsCovid 19 TestingVirtual Wellness Fair

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      Company Information: (Recommended)

      Host Company:

      Health Insurance (PPO or HMO, % if applicable)

      Dental Insurance (PPO or HMO, % if applicable)

      Vision Insurance (PPO or HMO, % if applicable)

      Alternative Coverage:

      Industrial Clinic:

      Tuition Reimbursement:

      Other Benefits:

      Are you self-Insured?

      Insurance Broker:

      Broker Contact / Phone # / Email

      Event Information: (If Applicable)

      Do you have multiple locations? (If yes, how many)

      Date(s) / Time of Event(s):

      Event Location / Address:

      Number of expected attendance:

      How many exhibitors / vendors would you like?

      Is this open enrollment?

      Are you including biometrics?

      Do you need a bid for biometric screenings? If so, check all that apply:

      Total cholesterolHDL/LDL cholesterolGlucoseBlood pressureBody FatOther: (List all that applies)

      Other biometric screenings:

      Any other information we should know: