Home
Contact
About Us
Updates
Menu
Home
Contact
About Us
Updates
Billing TIN Number
*
83-1312439
Patient First Name
*
Patient Middle name
Patient Last Name
*
Patient Date of Birth
*
Phone
*
Email
*
ID Type
*
State ID (DL)
SSN
Foreign ID
No ID
ID Number
*
Patient Gender
*
M
F
Ethnicity (optional)
American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latino
Native Hawaiian or Other Pacific Islander
White
Address
*
Address Line 1
City
State / Province / Region
Zip / Postal Code
Afghanistan
Åland Islands
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belau
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Saint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo (Brazzaville)
Congo (Kinshasa)
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Ivory Coast
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Kuwait
Kosovo
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
North Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Northern Mariana Islands
North Korea
Norway
Oman
Pakistan
Palestinian Territory
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Reunion
Romania
Russia
Rwanda
Saint Barthélemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin (French part)
Saint Martin (Dutch part)
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
San Marino
São Tomé and Príncipe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia/Sandwich Islands
South Korea
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom (UK)
United States (US)
United States (US) Minor Outlying Islands
Uruguay
Uzbekistan
Vanuatu
Vatican
Venezuela
Vietnam
Virgin Islands (British)
Virgin Islands (US)
Wallis and Futuna
Western Sahara
Samoa
Yemen
Zambia
Zimbabwe
Country
Service type
*
Professional
Date of Service
*
Testing Information
*
COVID 19 Ag Rapid
COVID-19 PCR TEST
Reason of test
*
Travel
Work
School
Possible Exposure to Covid-19
Confirmed Exposure to Covid-19
Other
Other Reason of test
Travel Date
Please, upload your ID
*
Drop your files here or click here to upload
You can upload up to 2 files.
Patient Signature
*
Please carefully read and sign the following Informed Consent: a. I authorize this laboratory testing unit to conduct collection and testing for molecular tests, as ordered by an authorized medical provider or public health official. b. I authorize my test results to be disclosed to the county, state, or to any other governmental entity as may be required by law. c. 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. d. 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 I will seek medical advice, care, and treatment from my medical provider if I have questions or concerns, or if my condition worsens. e. I understand that, as with any medical test, there is the potential for a false-positive or false-negative test result. I, the undersigned, 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 sign, and I have been told that I can ask additional questions at any time. I voluntarily agree to this testing.
Requesting Provider
Brian Jason Katz, MD Metro Pharmacy || Provider NPI# 1366984171 || MD Phone number 410-505-9500 & Fax 410-505-9505
Collected by
Afia Ahsan/Swati Koirala || 83-1312439 CLIA 21d2184231t
How did you hear about us?
*
Next Door Pharmacy
Drs Office
Urgent Care
Posted Signs
Google Search
Metro Website
Facebook
Instagram
Ads in apartment/property management
Friends or Family member
Pharmacy signs
Radio
Other
Other
Message
Submit
Gift card
For all new/transfer patients
$25
Transfer today