Facebook-f
Instagram
Linkedin
Twitter
[email protected]
800-269-0502
Home
Our Solutions
Compliance Solutions
Screening Services
About Us
Benefits of NMS
Our Team
Blog
Contact Us
Menu
Home
Our Solutions
Compliance Solutions
Screening Services
About Us
Benefits of NMS
Our Team
Blog
Contact Us
City of Fort Lauderdale (Fire)
(THIS AUTHORIZATION EXPIRES ONE YEAR AFTER IT IS SIGNED)
Information
*
Please enter information of those taking Quest and Labcorp based Coronavirus Test.
First Name
Last Name
Date of Birth
Phone Number
Sending Records From
NMS Management Services, Inc/Quest
Address:
2901 S. Congress Ave
Phone:
561-967-8884
Fax:
561-932-1597
City:
Palm Springs
State:
Florida
Zip:
33461
Sending Records To
City of Fort Lauderdale – Fire / Kathleen Thorpe
Address:
100 N Andrews Ave. 3rd Floor
Phone:
954-828-3609
City:
Fort Lauderdale
State:
FL
Zip:
33301
Email:
[email protected]
&
[email protected]
Authorizations
Type of Medical Request
*
All Laboratory Results
The laboratory is required to report all testing performed to the department of health.
I authorize the release of my COVID-19, Corona Virus , Antibodies Test Results, whether negative or positive to the person(s) listed above. I understand that the person(s) listed above will be notified that I must give specific written permission before disclosure of these test results to anyone.
*
Yes
You acknowledge and understand that NMS shall not be liable and shall be held harmless for any discomfort or any other derivative consequence of the process of specimen collection. It is understood that the process of collecting the specimen itself may involve an invasive process that can result in reflex reaction by the subject during the collection process. Further, it is understood that NMS is not responsible for the result or any consequence imposed upon the subject due to the result of the testing.
*
Yes
Disclaimer
*
I agree to the following disclaimer.
The COVID-19 Immunity (IgG) test does not directly detect the virus and should not be used to diagnose or exclude COVID-19 infection. A negative result may occur if you are tested early in your illness and your body hasn’t had time to produce antibodies to infection. Even if your COVID-19 Immunity (IgG) test is positive, that does not mean you are immune to COVID-19. If you suspect you may be infected with COVID-19, you should talk to your healthcare provider, and direct testing for the virus, COVID-19, should be performed.
Your Information
Your Name
*
First
Last
Address
*
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Copy of Driver's License
*
Accepted file types: png, pdf, jpeg, jpg, jpg2000, heic, tiff, Max. file size: 128 MB.
Δ