COVID-19 Drive Through Testing List – San Fernando Pediatrics and Urgent Care

Which COVID-19 test are you interested in? *

Rapid Antibodies
Rapid Nasal Swab Antigen
Nasal Swab PCR

If you are not sure which test is right for you, please call us at (818) 697-8585 and we will help you.

Results in up to 48 hours excluding Sundays.

This is the test you would need for travel clearance. This test is ideal for you if are just starting to feel sick, or if may have been recently exposed to someone who was positive.

A small pediatric size swab is inserted inside your nostril. The swab is then sent to the lab for the PCR test to detect the presence of COVID-19. This test will tell you if you have the virus now.

Results in 15 minutes.

This test is ideal for you if your symptoms started over 5 days ago, or if you want to know whether you have had the virus in the past and have developed antibodies against it. If you just developed symptoms today or in the past 3 days, the nasal swab PCR test would be the best test for you.

A small drop of blood is collected from your fingertip and is tested for the presence of COVID-19 antibodies. The results are available in 15 minute. This test will tell you if you have had the virus in the past and if you have the active virus as of 3 to 5 days ago.

Results in 15 minutes.

This test is ideal for you if are just starting to feel sick, or if may have recently been exposed to someone who was positive.

A small pediatric size swab is inserted inside your nostril. The swab is then tested to detect the presence of COVID-19. This test will tell you if you have the virus now.

Add-on Benefits

Flu Vaccine (Protects against 4 types of Flu)
Vitamin B12 shot (Boosts energy & immune system)

Flu shot: $0 copay with most insurance plans or $35 without insurance.

How many people to be tested? *

How many people to be tested? (PCR) *

How many people will get the Flu shot? *

How many people will get the B12 shot? *

Will you be using insurance? *

Please select your insurance correctly. We will not be able to call to book your appointment if false or incorrect information is provided.

Which insurance do you have? *

Please select your insurance correctly. We will not be able to call to book your appointment if false or incorrect information is provided.

Contact Information

Have you been to our clinic before? *

YES
NO

Welcome back 😊

Welcome 😊

Email *

Phone number *

This is the phone number we will call to book your appointment.

Please pick up the phone when you see a call from 818-697-8585 or call us back if you missed our call.

Address *

Address Line 1

City

State

Zip Code

Patient Information

Patient's Name *

First

Last

1st Patient's Date of Birth *

Patient's Date of Birth

1st Patient's Member ID & Group number *

First

Last

Insurance information

2nd Patient *

First

Last

2nd Patient's Date of Birth *

Patient's Date of Birth

2nd Patient's Member ID & Group number *

First

Last

Insurance information

3rd Patient *

First

Last

3rd Patient's Date of Birth *

Patient's Date of Birth

3nd Patient's Member ID & Group number *

First

Last

Insurance information

4th Patient *

First

Last

4th Patient's Date of Birth *

Patient's Date of Birth

4th Patient's Member ID & Group number *

First

Last

Insurance information

5th Patient *

First

Last

5th Patient's Date of Birth *

Patient's Date of Birth

5th Patient's Member ID & Group number *

First

Last

Insurance information

If you have an HMO insurance, your insurance will not pay us directly. You would pay for your visit and submit receipt to your insurance for reimbursement.

If you have Kaiser insurance, your insurance will not pay us directly. You would pay for your visit and submit receipt to your insurance for reimbursement.

Form of payment *

Credit Card
Debit Card
HSA Card

Total

$0.00

Credit Card *

Card Number

Security Code

Name on Card

Expiration/

I AGREE TO PAY THE ABOVE AMOUNT ACCORDING TO MY CARD HOLDER AGREEMENT. *

Clear Signature

Signature

Please upload a Picture ID for each adult patient or the parent (guardian) of underaged patients. *

Click or drag files to this area to upload. You can upload up to 10 files.

A photo ID is needed in order to book your appointment.

Please upload the picture of the front and back of the insurance card for each patient *

Click or drag files to this area to upload. You can upload up to 10 files.

To use your insurance, we must have a copy of the front and back of your insurance card.

We take your privacy seriously. Your information will NEVER be sold to, or shared with anyone outside of our HIPAA certified clinical team and billing department. By pressing confirm, you agree to our terms of service, financial policy, cancelation policy, privacy policy and arbitration agreement.

We take your privacy seriously. Your information will NEVER be sold to, or shared with anyone outside of our HIPAA certified clinical team and billing department. By pressing confirm, you agree to our terms of service, financial policy, cancelation policy, privacy policy and arbitration agreement. PHYSICIAN-PATIENT ARBITRATION AGaREEMENT. Article 1: Agreement to Arbitrate: It is understood that any dispute as to medical malpractice, that is as to whether any medical services rendered under this contract were unnecessary or unauthorized or were improperly, negligently or incompetently rendered, will be determined by submission to arbitration as provided by the law of the state of jurisdiction, and not by a lawsuit or resort to court process except as the law of the state of jurisdiction provides for judicial review of arbitration proceedings. Both parties to this contract, by entering into it, are giving up their constitutional right to have any such dispute decided in a court of law before a jury, and instead are accepting the use of arbitration. Article 2: All Claims Must Be Arbitrated: It is the intention of the parties that this agreement shall cover all claims or controversies whether in tort, contract or otherwise, and shall bind all parties whose claims may arise out of or in any way relate to treatment or services provided or not provided by ALI ANARI MD INC DBA SAN FERNANDO PEDIATRICS & URGENT CARE, the below identified physician, medical group or association, their partners, associates, associations, corporations, partnerships, employees, agents, clinics, and/or providers (hereinafter collectively referred to as “Physician”) to a patient, including any spouse or heirs of the patient and any children, whether born or unborn, at the time of the occurrence giving rise to any claim. In the case of any pregnant mother, the term “patient” herein shall mean both the mother and the mother’s expected child or children. Filing by Physician of any action in any court by the physician to collect any fee from the patient shall not waive the right to compel arbitration of any malpractice claim. However, following the assertion of any claim against Physician, any fee dispute, whether or not the subject of any existing court action, shall also be resolved by arbitration. Article 3: Procedures and Applicable Law: A demand for arbitration must be communicated in writing by U.S. mail, postage prepaid, to all parties, describing the claim against Physician, the amount of damages sought, and the names, addresses and telephone numbers of the patient, and (if applicable) his/her attorney. The parties shall thereafter select a neutral arbitrator who was previously a California superior court judge, to preside over the matter. Both parties shall have the absolute right to arbitrate separately the issues of liability and damages upon written request to the arbitrator. Patient shall pursue his/ her claims with reasonable diligence, and the arbitration shall be governed pursuant to Code of Civil Procedure §§ 1280-1295 and the Federal Arbitration Act (9 U.S.C. §§ 1-4). The parties shall bear their own costs, fees and expenses, along with a pro rata share of the neutral arbitrator’s fees and expenses. Article 4: Retroactive Effect: The patient intends this agreement to cover all services rendered by Physician not only after the date it is signed (including, but not limited to, emergency treatment), but also before it was signed as well. Article 5: Revocation: This agreement may be revoked by written notice delivered to Physician within 30 days of signature and if not revoked will govern all medical services received by the patient. Article 6: Severability Provision: In the event any provision(s) of this Agreement is declared void and/or unenforceable, such provision(s) shall be deemed severed therefrom and the remainder of the Agreement enforced in accordance with the law of the state of jurisdiction. I understand that I have the right to receive a copy of this agreement. By my signature below, I acknowledge that I have received a copy and I acknowledge to have been given enough time to read this agreement and given time to ask questions. After reading this agreement, I understand and agree with this arbitration agreement. NOTICE: BY SIGNING THIS CONTRACT YOU ARE AGREEING TO HAVE ANY ISSUE OF MEDICAL MALPRACTICE DECIDED BY NEUTRAL ARBITRATION AND YOU ARE GIVING UP YOUR RIGHT TO A JURY OR COURT TRIAL. SEE ARTICLE 1 OF THIS CONTRACT. The Physician:________________________________. Signature of the Physician:_______________________________. Date:___________________________. *

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Signature

We take your privacy seriously. Your information will NEVER be sold to, or shared with anyone outside of our HIPAA certified clinical team and billing department. We will help you with whatever we can, so that you may be reimbursed from your insurance company. By pressing confirm, you agree to our terms of service, financial policy, cancelation policy, privacy policy and arbitration agreement. By signing this form, I understand that San Fernando Pediatrics & Urgent Care is accepting me as a private-pay patient, and I am paying for the services I receive. The physician will not file a claim to my insurance provider or to Medicaid/Medi-CAL for the services provided for me.

We take your privacy seriously. Your information will NEVER be sold to, or shared with anyone outside of our HIPAA certified clinical team and billing department. We will help you with whatever we can, so that you may be reimbursed from your insurance company. By pressing confirm, you agree to our terms of service, financial policy, cancelation policy, privacy policy and arbitration agreement. By signing this form, I understand that San Fernando Pediatrics & Urgent Care is accepting me as a private-pay patient, and I am paying for the services I receive. The physician will not file a claim to my insurance provider or to Medicaid/Medi-CAL for the services provided for me.. PHYSICIAN-PATIENT ARBITRATION AGaREEMENT. Article 1: Agreement to Arbitrate: It is understood that any dispute as to medical malpractice, that is as to whether any medical services rendered under this contract were unnecessary or unauthorized or were improperly, negligently or incompetently rendered, will be determined by submission to arbitration as provided by the law of the state of jurisdiction, and not by a lawsuit or resort to court process except as the law of the state of jurisdiction provides for judicial review of arbitration proceedings. Both parties to this contract, by entering into it, are giving up their constitutional right to have any such dispute decided in a court of law before a jury, and instead are accepting the use of arbitration. Article 2: All Claims Must Be Arbitrated: It is the intention of the parties that this agreement shall cover all claims or controversies whether in tort, contract or otherwise, and shall bind all parties whose claims may arise out of or in any way relate to treatment or services provided or not provided by ALI ANARI MD INC DBA SAN FERNANDO PEDIATRICS & URGENT CARE, the below identified physician, medical group or association, their partners, associates, associations, corporations, partnerships, employees, agents, clinics, and/or providers (hereinafter collectively referred to as “Physician”) to a patient, including any spouse or heirs of the patient and any children, whether born or unborn, at the time of the occurrence giving rise to any claim. In the case of any pregnant mother, the term “patient” herein shall mean both the mother and the mother’s expected child or children. Filing by Physician of any action in any court by the physician to collect any fee from the patient shall not waive the right to compel arbitration of any malpractice claim. However, following the assertion of any claim against Physician, any fee dispute, whether or not the subject of any existing court action, shall also be resolved by arbitration. Article 3: Procedures and Applicable Law: A demand for arbitration must be communicated in writing by U.S. mail, postage prepaid, to all parties, describing the claim against Physician, the amount of damages sought, and the names, addresses and telephone numbers of the patient, and (if applicable) his/her attorney. The parties shall thereafter select a neutral arbitrator who was previously a California superior court judge, to preside over the matter. Both parties shall have the absolute right to arbitrate separately the issues of liability and damages upon written request to the arbitrator. Patient shall pursue his/ her claims with reasonable diligence, and the arbitration shall be governed pursuant to Code of Civil Procedure §§ 1280-1295 and the Federal Arbitration Act (9 U.S.C. §§ 1-4). The parties shall bear their own costs, fees and expenses, along with a pro rata share of the neutral arbitrator’s fees and expenses. Article 4: Retroactive Effect: The patient intends this agreement to cover all services rendered by Physician not only after the date it is signed (including, but not limited to, emergency treatment), but also before it was signed as well. Article 5: Revocation: This agreement may be revoked by written notice delivered to Physician within 30 days of signature and if not revoked will govern all medical services received by the patient. Article 6: Severability Provision: In the event any provision(s) of this Agreement is declared void and/or unenforceable, such provision(s) shall be deemed severed therefrom and the remainder of the Agreement enforced in accordance with the law of the state of jurisdiction. I understand that I have the right to receive a copy of this agreement. By my signature below, I acknowledge that I have received a copy and I acknowledge to have been given enough time to read this agreement and given time to ask questions. After reading this agreement, I understand and agree with this arbitration agreement. NOTICE: BY SIGNING THIS CONTRACT YOU ARE AGREEING TO HAVE ANY ISSUE OF MEDICAL MALPRACTICE DECIDED BY NEUTRAL ARBITRATION AND YOU ARE GIVING UP YOUR RIGHT TO A JURY OR COURT TRIAL. SEE ARTICLE 1 OF THIS CONTRACT. The Physician:________________________________. Signature of the Physician:_______________________________. Date:___________________________. *

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