premierdx

Patient Intake Form

Please complete the form below prior to your COVID-19 saliva or antibody test. Premier Diagnostics will not use your personal information outside of the healthcare context (e.g., reporting to local and federal agencies).

We are required by the health department to ask the following questions:

The following questions will help us determine if your test is eligible for insurance billing:

Serious heart conditions
Chronic lung disease
Asthma that is moderate to severe
Diabetes
Obesity (BMI > 40)
Liver Disease
Kidney Disease requiring dialysis
Current cancer treatment
Organ or bone marrow transplant
Sickle cell, thalassemia, or other hemoglobin disease
Taking medications that weaken the immune system (such as steroids)
Deficiencies of the immune system or HIV
None
Fever
Cough
Decreased sense of smell or taste
Sore or scratchy throat
Muscle aches/pains
Other
I don't have symptoms
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