Walk-in appointment  intake
arrow&v
arrow&v

Emergency Contact 

Insurance Information

arrow&v

Self-Pay 

arrow&v

Upload insurance card and Drivers License pictures

Upload (FRONT) insurance card

*Required

Upload (BACK) insurance card

*Required

Drivers License (FRONT)

*Required

Consent

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

arrow&v

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.

Thanks for submitting!