Super Health Pharmacy COVID-19 Form

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Image Field
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Select type of COVID-19 Test* This field is required.Your testing needs may be covered by your health insurance. Please call for details.
Rapid Covid-19 Antigen Test $25
Rapid Covid-19 PCR Nasal Swab Test $65 (Results within 15 minutes) Recommended for Travel, Medical Procedures, etc.
Rapid Flu A & B Test OR Rapid Strep A Test (Results within 15 minutes) $40
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Appointment For Rapid Flu A & B Test * This field is required.
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Appointment for Rapid COVID-19 Test* This field is required.One Appointment Per Person | Max one time slot PER patient
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Appointment
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Due to High Testing Demand, We do not allow appointment cancellations. Please verify with your end user if they will accept a RAPID COVID-19 Test as clearance, if this test is intended for such purpose. (i.e. work, travel, nursing home, hospital, etc.). By Submitting yes, you agree to our terms that Super Health Pharmacy will not be held responsible for any representations.* This field is required.
YESNO
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Date of Test* This field is required.Testing Starts At 10AM Daily!
Date
Month
Day
Year
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Pharmacy PhoneFor your reference
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Patient Name* This field is required.
First Name
Last Name
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Middle Initial
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Date of Birth* This field is required.MM/DD/YYYY
Please make sure your birthday is in this format (MM/DD/YYYY) otherwise your registration might be rejected (ex. 12/01/99)
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Patient Address * This field is required.
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City* This field is required.
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State* This field is required.
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ZIP Code* This field is required.
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Race** This field is required.Required By CDC
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Ethnicity** This field is required.Required By CDC
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Cell Phone* This field is required.
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Gender* This field is required.
MaleFemale
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Are you Pregnant/Postpartum?
YESNO
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COVID 19 (SARS CoV 2 Assay) via Nasal Swab* This field is required.
COVID 19 (SARS CoV 2 Assay) via Nasal Swab
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ICD-10 Code* This field is required.
Z20.828 Contact with and suspected exposure to other viral communicable disease
Z11.59 Asymptomatic, no known exposure, results unknown or negative
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Invoice ID
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Email *Very important your email is accurate for testing instructions.
example@example.com
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Picture of Government Issued IDDrivers License, Passport, Etc
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
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Secure Payment Portal* This field is required.Please select from the drop down
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ORDER SUMMARY
Total costUSD
Rapid COVID-19 TESTFastest way to get in and out is by paying online
$120.00+Edit
Back
Rapid Antigen Test
Rapid Antigen Test
Rapid PCR Test
Rapid Flu A & B or Rapid Strep
Insurance-If Covered
Rapid COVID-19 Test
Subtotal: $0.00
Total cost $0.00
Credit Card (Paying online is the fastest & safest method)
First Name
Last Name
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Thank you. Stay Healthy and See You Soon!
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