One Love

Patient Details

@csrf

First Name @if ($errors->has('fname'))

@endif

Last Name @if ($errors->has('lname'))

@endif

DOB @if ($errors->has('dob'))

@endif

City @if ($errors->has('city'))

@endif

State @if ($errors->has('state'))

@endif

Zip Code @if ($errors->has('zipcode'))

@endif

Phone# @if ($errors->has('phone'))

@endif

Gender @if ($errors->has('gender'))

@endif

Ethnicity @if ($errors->has('ethnicity'))

@endif

Address 1 @if ($errors->has('address_one'))

@endif

Address 2 @if ($errors->has('address_two'))

@endif

Documents

@if ($user->documents != null) @foreach ($user->documents as $document)

@endforeach @endif

Test Selection and Diagnosis Code Selection

Buccal Swab {{-- @if ($errors->has('buccal_swab'))

@endif --}}

COVID 19 SARS-COV-2 by RT-PCR

Covid-19 DX Code

Z20.828

Contact with and (suspected) expousre to other viral communicable diseases

Only to be used if actual expousre with someone confirmed to have COVID-19

@if ($errors->has('Z20828'))

@endif

@php if ($user->barcode != null) { $barCodeCreated = $user->barcode->created_at->format('Y-m-d h:i'); $barCodeExpire = \Carbon\Carbon::parse($barCodeCreated)->addDay(7)->format('Y-m-d h:i'); $today = \Carbon\Carbon::now()->format('Y-m-d h:i'); } else { $barCodeExpire = ''; } @endphp

@if (!empty($barCodeExpire) && $today >= $barCodeExpire)

BarCode ID

@else @if ($user->barcode != null)

BarCode ID

You can not change barcode till {{$barCodeExpire}} UTC (+00:00)

@else

BarCode ID

@endif @endif

Facility

Provider

NPI

Ethnicity

Race

Social Security

DL/State ID

Date of Collection

Time of Collection

Type of Specimen

Date Recived

ICD 10 Code

Insurance Type

Insurer

Relation to Insured

Policy ID

Group ID

Test Type

Test Option

Performing Laboratory @if ($errors->has('performing_lab'))

@endif

Previous Barcodes

@forelse ($barcodes as $barcode)

BarCode

@empty

No Previous Record Exists

@endforelse