In the past 14 days have you experienced any of the following symptoms? Fever >100, cough, fatigue, shortness of breath, change in taste or smell, nasal congestion, nausea or vomiting?
Have you been in close contact with someone who has tested positive for COVID-19 in the last 14 days?
What is your reason for visit?
I authorize Patriot Urgent Care Professionals, PC dba AFC Urgent Care to collect and keep my credit card information on file and to charge my credit card for any balance placed in patient responsibility by my health plan, not to exceed $250. I acknowledge that I will receive a call to confirm my appointment and give my credit card information. I further acknowledge that my appointment will be cancelled if I do not confirm the appointment and that if I do not arrive to my confirmed appointment this credit card will be charged a $50 fee.
I understand that if I select "Self-Pay" to pay for my visit that I do not have active health insurance
In the last 14 days, have you traveled to a state considered to be high risk for COVID-19 infection?
Are you currently a smoker?
Have you ever been a smoker?
Have you received your 2020 vaccine?
Is this appointment for COVID testing related to Travel, Return to Work, or Return to school? If Yes, we will be unable to process the visit through your health insurance and will instead collect $150 at the time of service for your visit.
