Book Appointment

Testing Time:*
- Appointment
- Walk-in
Appointment Time:*

July 2020

Mon Tue Wed Thu Fri Sat Sun

1 2 3 4 5
6 7 8 9 10 11 12
13 14 15 16 17 18 19
20 21 22 23 24 25 26
27 28 29 30 31

July 9, 2020

9:30 AM

9:45 AM

10:00 AM

10:15 AM

11:15 AM

11:30 AM

11:45 AM

12:00 PM

12:15 PM

12:30 PM

12:45 PM

1:15 PM

1:30 PM

1:45 PM

July 10, 2020

10:00 AM

10:15 AM

10:30 AM

10:45 AM

11:00 AM

11:15 AM

11:30 AM

11:45 AM

July 13, 2020

9:00 AM

9:15 AM

9:30 AM

9:45 AM

10:00 AM

10:15 AM

10:30 AM

10:45 AM

11:00 AM

11:15 AM

11:30 AM

11:45 AM

12:00 PM

12:15 PM

12:30 PM

12:45 PM

1:00 PM

1:15 PM

1:30 PM

1:45 PM

July 14, 2020

9:00 AM

9:15 AM

9:30 AM

9:45 AM

10:00 AM

10:15 AM

10:30 AM

10:45 AM

11:00 AM

11:15 AM

11:30 AM

11:45 AM

12:00 PM

12:15 PM

12:30 PM

12:45 PM

1:00 PM

1:15 PM

1:30 PM

1:45 PM

July 15, 2020

9:00 AM

9:15 AM

9:30 AM

9:45 AM

10:00 AM

10:15 AM

10:30 AM

10:45 AM

11:00 AM

11:15 AM

11:30 AM

11:45 AM

12:00 PM

12:15 PM

12:30 PM

12:45 PM

1:00 PM

1:15 PM

1:30 PM

1:45 PM

July 16, 2020

9:00 AM

9:15 AM

9:30 AM

9:45 AM

10:00 AM

10:15 AM

10:30 AM

10:45 AM

11:00 AM

11:15 AM

11:30 AM

11:45 AM

12:00 PM

12:15 PM

12:30 PM

12:45 PM

1:00 PM

1:15 PM

1:30 PM

1:45 PM

July 17, 2020

9:00 AM

9:15 AM

9:30 AM

9:45 AM

10:00 AM

10:15 AM

10:30 AM

10:45 AM

11:00 AM

11:15 AM

11:30 AM

11:45 AM

July 20, 2020

9:00 AM

9:15 AM

9:30 AM

9:45 AM

10:00 AM

10:15 AM

10:30 AM

10:45 AM

11:00 AM

11:15 AM

11:30 AM

11:45 AM

12:00 PM

12:15 PM

12:30 PM

12:45 PM

1:00 PM

1:15 PM

1:30 PM

1:45 PM

July 21, 2020

9:00 AM

9:15 AM

9:30 AM

9:45 AM

10:00 AM

10:15 AM

10:30 AM

10:45 AM

11:00 AM

11:15 AM

11:30 AM

11:45 AM

12:00 PM

12:15 PM

12:30 PM

12:45 PM

1:00 PM

1:15 PM

1:30 PM

1:45 PM

July 22, 2020

9:00 AM

9:15 AM

9:30 AM

9:45 AM

10:00 AM

10:15 AM

10:30 AM

10:45 AM

11:00 AM

11:15 AM

11:30 AM

11:45 AM

12:00 PM

12:15 PM

12:30 PM

12:45 PM

1:00 PM

1:15 PM

1:30 PM

1:45 PM

July 23, 2020

9:00 AM

9:15 AM

9:30 AM

9:45 AM

10:00 AM

10:15 AM

10:30 AM

10:45 AM

11:00 AM

11:15 AM

11:30 AM

11:45 AM

12:00 PM

12:15 PM

12:30 PM

12:45 PM

1:00 PM

1:15 PM

1:30 PM

1:45 PM

July 24, 2020

9:00 AM

9:15 AM

9:30 AM

9:45 AM

10:00 AM

10:15 AM

10:30 AM

10:45 AM

11:00 AM

11:15 AM

11:30 AM

11:45 AM

July 27, 2020

9:00 AM

9:15 AM

9:30 AM

9:45 AM

10:00 AM

10:15 AM

10:30 AM

10:45 AM

11:00 AM

11:15 AM

11:30 AM

11:45 AM

12:00 PM

12:15 PM

12:30 PM

12:45 PM

1:00 PM

1:15 PM

1:30 PM

1:45 PM

July 28, 2020

9:00 AM

9:15 AM

9:30 AM

9:45 AM

10:00 AM

10:15 AM

10:30 AM

10:45 AM

11:00 AM

11:15 AM

11:30 AM

11:45 AM

12:00 PM

12:15 PM

12:30 PM

12:45 PM

1:00 PM

1:15 PM

1:30 PM

1:45 PM

July 29, 2020

9:00 AM

9:15 AM

9:30 AM

9:45 AM

10:00 AM

10:15 AM

10:30 AM

10:45 AM

11:00 AM

11:15 AM

11:30 AM

11:45 AM

12:00 PM

12:15 PM

12:30 PM

12:45 PM

1:00 PM

1:15 PM

1:30 PM

1:45 PM

July 30, 2020

9:00 AM

9:15 AM

9:30 AM

9:45 AM

10:00 AM

10:15 AM

10:30 AM

10:45 AM

11:00 AM

11:15 AM

11:30 AM

11:45 AM

12:00 PM

12:15 PM

12:30 PM

12:45 PM

1:00 PM

1:15 PM

1:30 PM

1:45 PM

July 31, 2020

9:00 AM

9:15 AM

9:30 AM

9:45 AM

10:00 AM

10:15 AM

10:30 AM

10:45 AM

11:00 AM

11:15 AM

11:30 AM

11:45 AM
Service:
Provider:

Mon	Tue	Wed	Thu	Fri	Sat	Sun
		1	2	3	4	5
6	7	8	9	10	11	12
13	14	15	16	17	18	19
20	21	22	23	24	25	26
27	28	29	30	31

Employment Information
Occupation:
Employer: Phone #:
Address:
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Primary Insurance Information
Do you have insurance?*
- YES
- UNINSURED
Primary Insured Relationship:*
- Self
- Spouse
- Parent
Primary Insured Name:*
Primary Insured Date of Birth:*
Date Format: MM slash DD slash YYYY
Insurance Company:*
Primary Insured Social Security Number:*
Member ID#*
Group#*

Secondary Insurance Information
Do you have secondary insurance?*
- YES
- NO
Primary Insured Name:*
Primary Insured Date of Birth:*
Date Format: MM slash DD slash YYYY
Insurance Company:*
Primary Insured Social Security Number:*
Member ID#*
Group#*
Primary Insured Relationship:*
- Self
- Spouse
- Parent
Responsible Party (if other than patient):
Relationship To Patient: Last Name: First Name:
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Family Medical History
Please only include people who are your blood relatives (not adopted or step family). Please note if they are Alive or deceased and their ages. Include any family who died before the age of 55.
Father's Medical Issues:
Mother's Medical Issues:
Sibling's Medical Issues:
Other Family Medical Issues:

I hereby give Stephen P Dubin Inc permission to release my records to all required entities:*
- Select All
- Southern Nevada Health District
- Accu Reference/ Clarity Labs
- Center for Disease Control (CDC)
By signing below, I certify the above information is correct.*
** The COVID-19 testing will be covered by the CDC Guidelines. Stephen P. Dubin MD Inc and Core Diagnostics Laboratories will bill your insurance Company. No One will be Denied due to the inability to Pay.
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COVID 19 Testing Appointment Form

Step 1 of 8

July 2020

July 9, 2020

July 10, 2020

July 13, 2020

July 14, 2020

July 15, 2020

July 16, 2020

July 17, 2020

July 20, 2020

July 21, 2020

July 22, 2020

July 23, 2020

July 24, 2020

July 27, 2020

July 28, 2020

July 29, 2020

July 30, 2020

July 31, 2020

Patient Information

Employment Information

Primary Insurance Information

Secondary Insurance Information

Family Medical History

Health Care Maintenance

Lifestyle

** The COVID-19 testing will be covered by the CDC Guidelines. Stephen P. Dubin MD Inc and Core Diagnostics Laboratories will bill your insurance Company. No One will be Denied due to the inability to Pay.