Do You Want to Know if You Have Neutralizing Antibodies to COVID-19?

PLEASE USE FORM BELOW TO ENROLL INTO THIS PROGRAM

NQATP Registration

ATTENTION: If you have active COVID-19 infection or your last COVID-19 RT-PCR or Rapid point-of-care diagnostic test was positive, you ARE NOT ELIGIBLE FOR THIS PROGRAM at this time! Please don’t fill out this form.

YOU CAN REGISTER ONCE YOU HAVE TESTED NEGATIVE FOR COVID-19

    *Biological Sex (required)
    MaleFemale

    *Ancestry (required)
    CaucasianAfrican AmericanAsianHispanicOther

    *Medical Conditions (required)
    DiabetesHeart ConditionAsthmaHypotensionObesityNone of Mentioned

    *Did You Receive COVID-19 Vaccine? (required)
    YESNO

    If YES, Which One?
    PfizerModernaOther

    *Where You Diagnosed with COVID-19? (required)
    YESNO

    *Did You receive Monoclonal Antibody Infusion? (required)
    YESNO

    If YES, Which One?
    BamlanivimabCasirivimab/Imdevimab

    I understand that personal information will not be shared and will be kept confidential by Ayass BioScience, LLC. If If I am covered by insurance, I authorize Ayass BioScience, LLC to give my designated insurance carrier(s) plan on this form and other information provided by my health care provider necessary for reimbursement. I authorize Ayass BioScience, LLC to inform my Plan of my test results only if test results are required for preauthorization of or payment for reflex/additional testing. I authorize Plan benefits to be payable to Ayass BioScience, LLC. I further authorize payment of benefits directly to the laboratory. I understand acceptance of insurance does not relieve me from any responsibility concerning payment for laboratory services and that I am financially responsible for all charges whether or not they are covered by my insurance. I understand that any payment I receive for services rendered by the laboratory from my insurance provider should be forwarded immediately to the laboratory. I understand that if I don't have an insurance, I am financially responsible for all charges.

    *I do consent for the remaining part of my sample to be used for research purposes by Ayass BioScience, LLC. (required)
    YESNO

    All tests are performed in Ayass BioScience, LLC. Ayass BioScience, LLC (DBA Ayass Laboratory, LLC) is a CLIA certified laboratory. If you have any questions about Ayass BioScience, LLC, Our Testing, NQATP, Drive-Through Testing for COVID-19, please call today at 972-668-6005, or COVID-19 HOTLINE at 469-415-1600, or fill out our contact form on the bottom of this page. We will answer any question you might have.