If you're having issues with this form please call +1 (833) 231-8190


If you are registering for an At-Home Covid-19 Collection Kit, and your camp arrival date is less than 7 business days from now, do not order using this form.
Please call 833-231-8190 instead. We’ll work with you to ensure your kit will arrive in time to complete specific collection and testing requirements.

Testing Type
It takes 4-7 business days to deliver from the day you have ordered. If you don't order in time, you can choose to test at our facility.

CommunityLab Address :

2 Trident Dr

Arden NC 28704


Lab Hours:

Monday - Friday 9.00AM - 5.30PM

Do not come at 12.00 - 1.00PM (Collection is closed for lunch)

Saturday 9.00 - 11.30 AM

Test on Our Facility Date

Earliest to test is 3 days before the camp.


Test result needs 24 hrs to produce. 

Please plan properly.

By providing your mobile number, you consent to receive automated calls and/or text messages about this test.

By providing your email, you consent to receive important information, result availability, and access details to your test results through the email provided below.

Important Testing Information

Is this your first COVID-19 Test?*
Staff Name*
Date of Birth*
mm/dd/yyyy
Have you experienced any of the following Symptoms? (Select any that apply)
If you select one or more of the above symptoms, you will be required to enter symptom onset date.
Symptom Onset Date
Do you have any of the following medical conditions? (Select any that apply)
In the past 14 days, have you had known or suspected exposure to the SARS-CoV-2 virus or a COVID-19 patient?
(e.g. been exposed to someone with COVID-19 or been in a large public gathering where exposure is suspected)
Have you been prioritized for testing by a medical professional?
Do you work in a special setting where the risk of COVID-19 transmission may be high?
(This may include long-term care, correctional and detention facilities; homeless shelters; assisted-living facilities and group homes.)
Are you a resident in a special setting where the risk of COVID-19 transmission may be high?
(This may include long-term care, correctional and detention facilities; homeless shelters; assisted-living facilities and group homes.)
If applicable, are you currently pregnant?
Employed in healthcare?
Use your mouse or finger to draw your signature above

Patient Demographics

Patient Address*
Mailing address for the Camper's location one week prior to their arrival date (if different from Permanent Address).
Bypass address requirement for special circumstances.
Responsible Name*
I authorize CommunityLab to leave a detailed message regarding my visit today on the voicemail of the telephone number I have provided.

Test Coverage Information

Do you have health insurance?
(Private/Medicare/Medicaid/Other Health Plans)
Who is the policy holder?*
Insured Name*
Insured Date of Birth*
Ages 10 -17 - Parent or legal guardian must fill out form.

BCBS of NC- must have 14 characters to be complete

This is comprised of 3 letters followed by numbers ending with 2-digit number that represents the patient

Example YPP123456789 (suffix 00 is for subscriber) (01 for spouse or child)

Federal starts with an R

Medicare no longer uses SSN number. Please find the policy number on your card.

  • Medcost, Healthscope and Meritain must also include the group number
  • WellCare policy number - policy number starts with number 3
  • UHC/ United Health Care - policy number starts with number 9
  • AmeriHealth Caritas- policy number should be 13 digit number
most often found on insurance card
optional
My personal health information may be made available electronically to other healthcare providers who have a treatment relationship with me or to my health plan for operations and care coordination as permitted by Federal and State laws.*
No File Chosen
File uploads may not work on some mobile devices.
No File Chosen
File uploads may not work on some mobile devices.
No File Chosen
File uploads may not work on some mobile devices.

IMPORTANT REMINDER
If there are multiple campers or staff who are being tested, each person being tested must complete this form for the laboratory to process the test. After submitting this from you will be redirected to confirmation page, then complete a new form.

INFORMED CONSENT FOR CORONAVIRUS (COVID-19) TESTING

Please carefully read and sign the following informed consent:

  1. I authorize this COVID-19 testing unit to conduct collection and testing for COVID-19 through saliva collection as ordered by an authorized medical provider, public health official, or by guidance from CDC and CMS.
  2. I authorize the test results to be disclosed to the county, state, or to any other governmental entity as may be required by law. Additionally, I specifically authorize the results to be released to the following organizations:
    Camp Rockbrook
  3. I acknowledge that a positive test result is an indication that the individual being tested must continue to self-isolate in an effort to avoid infecting others.
  4. I understand the testing unit is not acting as my medical provider, this does not replace treatment by my medical provider, and I assume complete and full responsibility to take appropriate action with regards to the test results. I agree that I will seek medical advice, care and treatment from a medical provider if I have questions or concerns, or if conditions worsens.
  5. I understand that, as with any medical test, there is the potential for false positive or false negative test results.



Date/Time*
Use your mouse or finger to draw your signature above

Confirmation Page

Name:  {$124620591 ‪Who is getting testing?‬}

Date of Birth:  {$124620592 ‪Date of Birth‬}

Mobile Phone:  {$124620587 ‪Mobile Phone (Used for Registration Confirmation)‬}

Email:  {$124620588 ‪Email (Used for PDF Result Access)‬}

Arrival Date:  {$124620585 ‪Camp Arrival Date‬} 

 

 

 

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