Super Health Pharmacy COVID-19 Form

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2
Date of Test
Date
Month
Day
Year
3
Time Specimen
4
Accession
5
Street Address
6
Pharmacy Phone For your reference
7
Patient Name* This field is required.
First Name
Last Name
8
Middle Initial
9
Date of Birth* This field is required.MM-DD-YYYY
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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.
14
Race** This field is required.Required By CDC
15
Ethnicity** This field is required.Required By CDC
16
Cell Phone* This field is required.
17
Insured's Name
18
Relationship to Patient
19
Gender* This field is required.
20
Primary InsuranceName of Insurance Company
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Group #
22
ID#
23
COVID 19 (SARS CoV 2 Assay) via Nasal Swab* This field is required.
COVID 19 (SARS CoV 2 Assay) via Nasal Swab
24
ICD-10 Code* This field is required.
Z03.818 Possible exposure to COVID 19, ruled out
Z11.59 Asymptomatic, no known exposure, results unknown or negative
25
Email *Needed if you need the results emailed to you directly from Lab
example@example.com
26
Picture of Government Issued IDDrivers License, Passport, Etc
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
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27
Picture of Insurance Card
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
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Should be Empty: