3066 E. Meridian Park Loop, Wasilla, AK 99654 Office: (907) 357-9560 Fax: (907) 357-9596

New Client Information SheetCOVID Testing Only

NEW CLIENT

Company Name

Physical Address

City, State, Zip

Phone

BILLING CONTACT DATA

Check if billing address is the same as above

Indicate billing delivery method Fax Mail

Billing Contact Name (Name on invoice)

Billing Contact Phone

Billing Address

City, State, Zip

Please indicate any special instructions:

RESULT REPORTING

Who should receive results of exams and

evaluations? DER (same individual(s) as in section 10 below) Others

If others, list (use additional sheets if necessary): Name

Phone: Primary/Secondary/FAX

e-mail

e-Mail

COVID testing is conducted:

In Anchorage at 301 Calista Court, Anchorage, Alaska from 0630 to 1830AST.In Wasilla at 3122 East Meridian Park Loop, Wasilla, Alaska from 0800 to 2000 AST Monday through Friday and 1000 to 1800 AST Saturday and Sunday.In the Ted Stevens International Airport, Terminal B across from Humpey's, 24 hours a day 7 days a week.In Dillingham, Animal Control Facility across from boat harbor, 0600 to 1800 7 days a week.In Kenai, 10543 Kenai Spur Hwy, Kenai, Alaska from 0900 to 1700 Monday through Friday (special accommodation on weekends available).

We are able to accommodate most special timing requests. Give us a call at (682) 216-6392 to discuss any special testing needs.

DESIGNATED EMPLOYEE REPRESENTATIVES (DER)

A Primary DER is the employee (or employees) from your company that is (are) responsible for the administration of your company’s account with Capstone. Capstone requires at least one Primary DER and one Alternate DER.An Alternate DER Authorization Form must be completed for each Alternate DER. For multiple Alternate DER’s, please make copies of this form. Incomplete forms may result in processing delays.

Primary DER

Name (Last, First, MI)

Results to be received Negatives Positives

Primary Phone

Secondary Phone

Fax

Email

Notification Method Email

Alternate DER #1

Name (Last, First, MI)

Results to be received Negatives Positives

Primary Phone

Secondary Phone

Fax

Email

Notification Method Email

3066 E. Meridian Park Loop, Wasilla, AK 99654 Office: (907) 357-9560 Fax: (907) 357-9596

Fax

Fax

Date

Authorized Representative

Authorized Representative Signature

Capstone Use Only

Received by Date

Submit to Billing

Submit to Contracting

Submit to Employee Health