Walk-in appointment  intake

Emergency Contact 

Insurance Information

Self-Pay 

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Consent

I hereby give my consent for the following test to be performed at PCG Molecular, LLC.

Consent to bill insurance

I understand and grant permission to PCG Molecular, LLC to bill my insurance for laboratory services provided. I understand that service may not be covered by insurance. I further understand that I may be responsible for co-pays, deductibles, and any amount not covered by my insurance. By signing below, I acknowledge that payment may be made on behalf to PCG Molecular, LLC. I hereby authorize the ordering physician and or/ clinic to disclose any personal medical information that may be needed to process claims related to services rendered by PCG Molecular, LLC and its affiliates.

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