COVID-19 SCREENING FORM
Please fill out this form prior to your appointment with Metro Drugs Rx for a COVID-19 test. All questions with a red star are MANDATORY.
Date of Birth
Street Address Line 2
State / Province
Postal / Zip Code
Please select all applicable :
I am a resident of New-York City or NY State
I am a first responder employed in NYC or NY State
I am a hospital employee at a hospital located in NY
Employee at the county or a local municipality
Do you have any of the following symptoms?:
New and persistent dry cough
Shortness of breath or difficulty breathing, shortness of breath
Diarrhoea and/or nausea
Fever of 100.4 degrees or greater
Fever Result (last taken)
Are you currently on any long-term treatment?
Have you been in contact with anyone in the last 14 days who is experiencing these symptoms?
Have you been in contact with anyone who has since tested positive for Covid-19?
Have you travelled abroad in the last 1-2 months? Where did you go?
COVID-19 test preference :
Were you referred by your physician or insurance or did you find us via COVID-19 Official Apple Online Services?
Yes, my physician (type name in "other" box)
Yes, my insurance (type name in "other" box)
Do you have a prescription?
Are you covered by your health insurance for this test?
If YES, please select your insurance
Blue Cross Blue Shield
Upload a photo or scan of your photo ID
Upload a photo or scan of your insurance card
Patient Signature :
Should be Empty: