COVID-19 Screening Survey

We perform our evaluation, testing and physician consultation inside the Advanced Dallas Emergency Department. So, please check in at our Emergency Room desk at the time of your appointment. Each patient’s symptoms and results will be reviewed by one of our emergency physicians during the time of testing to determine if any treatment and/or additional interventions are necessary. Your insurance will be billed for the hospital services and professional services related to this visit. Your health insurance carrier should cover the expenses associated with your COVID testing in full regardless of deductible and co-pays; consequently, you should not receive a bill for these services.

Please answer the questions below to help determine eligibility.

• 1.What is your reason for needing a COVID-19 test?
  • I currently have symptoms concerning for an active COVID infection.
  • I was exposed to someone for at least 15 minutes who tested positive.
  • I tested positive for COVID and I am currently still having symptoms.
  • I have no symptoms, but require a negative test in order to return to work/return to school/travel abroad.
    • COVID testing for these indications is generally not covered by insurance carriers. We can offer you testing at a cash price of $200.
      • I wish to proceed with testing.
      • I do not wish to proceed with testing.
  • My physician ordered a test prior to surgery/procedure.
    • Is your surgery/procedure scheduled at River Oaks Hospital or East Houston Hospital?
      • Yes
      • No
        • COVID testing for these indications is generally not covered by insurance carriers. We can offer you testing at a cash price of $200.
          • I wish to proceed with testing.
          • I do not wish to proceed with testing.
• 2.Are you experiencing any of the following symptoms?
  (Select all that apply)
  • Fever/Chills
  • Cough
  • Shortness of Breath
    • Are you experiencing SEVERE shortness of breath?
      • Yes
      • No
  • Fatigue
  • Muscle/Body Aches
  • Headache
  • New Loss of Taste or Smell
  • Sore Throat
  • Congestion or Runny Nose
  • Nausea or Vomiting
  • Diarrhea
  • Other
    • Please describe the symptoms you are experiencing.
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