Existing Dental Patient-Request for an Appointment

COVID-19 Rapid Antibody Testing Request

Capital Area Health Network is committed to ensuring the safety and well-being of our patients, employees, and community during the COVID-19 pandemic. To ensure we can still provide healthcare access during this time, we have instituted an additional precaution: SD BioSensor Rapid Test. This antibody test is administered by our medical staff and is required of all patients prior to being seen by our dental staff. For those without medical insurance, there is a $50 fee.
Full Name *

First Name Last Name
Date of Birth *

Month Day Year
Date of Dental Appointment: *

Month Day Year
Date
Time of Dental Appointment *

: Hour Minutes AM/PM Option
Phone Number *

Area Code Phone Number
E-mail
Gender Identity *
Race *
Ethnicity *
Insurance

For those without medical insurance, there is a $50 fee.
Do you have medical Insurance?: *

Yes No
Name of Insurance Company *
Member ID:
Group ID Number
Please upload an image of the FRONT of your Insurance card.

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PlNumberease upload an image of the FRONT of your Insurance card.

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How do we contact you?
After submission of this form, you will be scheduled for a virtual visit with one of our medical providers before a curbside test is performed. Please select all that apply: *

I have a smart phone with internet access and/or a data plan I have a computer/laptop with a camera and internet access I have a tablet with a camera and internet access I do not have access to any of the above
To complete the antibody test, a representative will tell you the time and location of your drive-up appointment. Please state the make, model and color of your vehicle. *
Vehicle make and model
Vehicle Color *
I understand The SD Biosensor Test is an antibody test and is not being given to diagnose a patient’s COVID-19 status. It only gauges exposure to the virus by evaluating the presence of antibodies. This will provide our staff with data needed to determine safe approaches to treating a patient.
I agree that the information supplied on this form is accurate and up-to-date to the best of my knowledge. *

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COVID-19 Rapid Antibody Testing Request

Insurance

How do we contact you?