COVID 19 Testing Patient Information Sheet
To ensure your safety testing is done by appointment. Call 630-357-1030.
Thank you for choosing our office. In order to properly serve you please complete this form. Print your answers.
A physical exam is recommended for every child tested since COVID symptoms are similar to FLU, Strep Throat and
common colds. Check here if you want your child examined by our physicians and tested for other illnesses.
PATIENT(S) to be tested – List yourself and then any household member who is also being tested. Enter
the phone number of any person using a different number than listed in first space. If not, leave blank.
Full Name
(First, MI, Last)
Phone
(Area code and number)
PATIENT(S) Demographics – print your complete address and circle your answers.
Current Mailing Address (Number and Street) City State Zip code
_____________________________________________________________________________
Race (pick one) African American American Indian Ethnicity (pick one.)
Asian Caucasian Pacific Islander/Alaskan Other Hispanic Non-Hispanic
PAYMENT INFORMATION
Do you have medical insurance? Yes No If Yes, does your insurance company participate with us? Yes No
Please note: we are not able to file insurance claims to every company. As a pediatric office, we cannot accept Medicare.
If not using insurance, our out of pocket charge for a COVID19 Rapid Antigen Test is $60 payable by cash or credit card
at the time of service. To use insurance, you must present your insurance card at the time of testing or provide a copy of
the back and front of the card.
____________________________________________________________________________________________________________________________________
If using insurance, complete this section.
1. I authorize this office to release any information necessary to process insurance claims.
2. I understand that I am responsible for all charges, regardless of insurance coverage.
3. I hereby assign payment of medical insurance benefits to Naperville Pediatric Associates.
4. I authorize the release of a copy of this authorization to be used in place of the original.
5. I certify that the above information is correct.
Signature Date Relation to Patient(s)
Consent for Treatment Must be signed and dated
I consent to COVID 19 rapid antigen testing by swabbing my nostrils with a Dacron tip test swab performed by the
attending physician or his/her assistant or designee as may be necessary in his/her best medical judgment.
Signature Date Relation to Patient(s)
Phone to call _____________________Date of testing ____________________ Needs a paper result: Yes No
After completing this form, print and bring it with you or you can email a pdf copy to pedsprint@hpeprint.com .
click to sign
signature
click to edit
![]()
click to sign
signature
click to edit
![]()
