Covid Testing Intake Form
Facilitated by Alpha NB Consulting

https://www.AlphaNB.com/Covid

Please complete the entire form.
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Agent Referral Code *
If no code provided, please enter ANB000.
Client Name *
Client Type *
Client Location Address (If Multiple, please list all) *
If out of state, do you require FREE Incoming/Outgoing delivery?
Clear selection
What is the item you would like to order? *
Please Enter the test type. Ex. 10 Min Rapid Antigen test + PCR test   or   PCR Test Only
Client Point of Contact *
Client Phone Number *
Client Email *
How many tests are required to begin? *
Please estimate as closely as possibly. All unused tests must be returned with return shipment.
Are any individuals repeat test? *
How Frequently would the client want testing? *
Ex. 15 min Rapid is usually once a day and PCR is once a week. Can be as frequent as you would like.
How many will be projected per frequency indicated above? *
When would the client like to begin testing? *
Please put a date and if you require shipping, add up to two days past for first shipment.
Onboarding Instructions
1. Please email Covid@alphanb.com for additional requests such as PPE or even purchasing your own test kits!

2. The address and company name provided will be printed on all of the patient results data. The QR form time that is submitted will be the collected time stamp on each result.

3. You will receive an email with a QR form/digital check in link so that patients can check in online.

4.If you are conducting rapid antigen testing, it is imperative that you complete our Excel daily tracker that has names, DOB, positives/negatives for each patient and that those results be emailed to us daily

5. If you are requesting pickups for out of state tests, please request a return UPS or FedEx Next Day Air shipping label from us. Pickup then can be scheduled by your staff calling FedEx or UPS to pickup from your location or by dropping to the respective carriers locations. Please be conscious of last Air pickup times for your area and ensure samples are given before that pickup

For UPS pickups: 1-800-PICK-UPS 742-5877
For FedEx pickups: 1-800-GOFEDEX 463-3339

6. Please ensure kits are sent back the same day as the patient is swabbed. Carriers do not service on Sundays and hours may be limited on Saturdays.

7. Please ensure that test tubes have Name and DOB on each tube


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This form was created inside of National Testing.