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).
Person being tested
May use legal guardian's email address for minors
May use legal guardian's phone number for minors. Please enter 10-digit number without parentheses or dashes
E.g., Utah, Salt Lake, Weber, Davis
Based on your response, we have determined that your test does not qualify for insurance billing. However, we are still able to provide you a COVID-19 test at a discounted price of $125 for the saliva-based PCR test and $50 for the antibody test. Please complete your registration by making this payment with a debit or credit card using the form below.
The saliva-based COVID-19 PCR test detects the presence of the virus in your body and is accepted as a diagnostic test by major governments and the medical community. The COVID-19 antibody test detects the presence of IgG and IgM antibodies in your bloodstream, suggesting that you have had COVID-19 in the past or were exposed and successfully fought off the virus. We recommend taking both tests in order to have a full understanding of your diagnosis and exposure to COVID-19.
Based on your response, we have determined that your test qualifies for insurance billing. Next, we will ask you information about your insurance provider (note, you can still proceed if you are uninsured)
I understand that as part of my healthcare, this Practice originates and maintains health records describing my health history, symptoms, examination and test results, diagnosis, treatment, and any plans for future care or treatment. By clicking 'accept' you agree to the terms of the HIPAA Privacy Rule of Patient Authorization Agreement. I also give my permission to release my test results to other healthcare providers.
Please carefully read and indicate acceptance of the following Informed Consent:
I (or legal guardian for minors) authorize this COVID-19 testing unit to conduct collection and testing for COVID-19 through a saliva sample or blood sample, as ordered by an authorized medical provider or public health official.
I authorize my test results to be disclosed to the county, state, or to any other government entity as may be required by law.
I acknowledge that a positive test result is an indication that I must self-isolate and/or wear a mask or face covering as directed in an effort to avoid infecting others.
I understand the testing unit is not acting as my medical provider, this testing does not replace treatment by my medical provider, and I assume complete and full responsibility to take appropriate action with regards to my test results. I agree that I will seek medical advice, care and treatment from my medical provider if I have questions or concerns, or if my condition worsens.
I understand that, as with any medical test, there is the potential for a false positive or false negative COVID-19 test result.
Release: To the fullest extent permitted by law, I hereby release, discharge and hold harmless, Premier Diagnostics/Alta Canyon Spine/Sports Medicine Research Testing Laboratory/Advanced Testing Services/Orca Health, including, without limitation, any of its respective officers, directors, employees, representatives and agents from any and all claims, liability, and damages, of whatever kind or nature, arising out of or in connection with any act or omission relating to my COVID-19 diagnostic test or the disclosure of my COVID-19 test results.
I have been informed about the test purpose, procedures, possible benefits and risks, and I have received a copy of this Informed Consent. I have been given the opportunity to ask questions before I click Accept, and I have been told that I can ask additional questions at any time. I voluntarily agree to this testing for COVID-19.