You can always press Enter⏎ to continue
COVID-19 Test Appointment Request
COVID-19 Test Appointment Request
21Questions
COVID-19 Test Appointment Request
Language
  • English (US)
  • 1
    Press
    Enter
  • 2
    Press
    Enter
  • 3
    Pick a Date
    Press
    Enter
  • 4
    Select from drop down list
    • Male
    • Female
    • Unknown
    Press
    Enter
  • 5
    Please Select
    • Please Select
    • United States
    • Afghanistan
    • Albania
    • Algeria
    • American Samoa
    • Andorra
    • Angola
    • Anguilla
    • Antigua and Barbuda
    • Argentina
    • Armenia
    • Aruba
    • Australia
    • Austria
    • Azerbaijan
    • The Bahamas
    • Bahrain
    • Bangladesh
    • Barbados
    • Belarus
    • Belgium
    • Belize
    • Benin
    • Bermuda
    • Bhutan
    • Bolivia
    • Bosnia and Herzegovina
    • Botswana
    • Brazil
    • Brunei
    • Bulgaria
    • Burkina Faso
    • Burundi
    • Cambodia
    • Cameroon
    • Canada
    • Cape Verde
    • Cayman Islands
    • Central African Republic
    • Chad
    • Chile
    • China
    • Christmas Island
    • Cocos (Keeling) Islands
    • Colombia
    • Comoros
    • Congo
    • Cook Islands
    • Costa Rica
    • Cote d'Ivoire
    • Croatia
    • Cuba
    • Curacao
    • Cyprus
    • Czech Republic
    • Democratic Republic of the Congo
    • Denmark
    • Djibouti
    • Dominica
    • Dominican Republic
    • Ecuador
    • Egypt
    • El Salvador
    • Equatorial Guinea
    • Eritrea
    • Estonia
    • Ethiopia
    • Falkland Islands
    • Faroe Islands
    • Fiji
    • Finland
    • France
    • French Polynesia
    • Gabon
    • The Gambia
    • Georgia
    • Germany
    • Ghana
    • Gibraltar
    • Greece
    • Greenland
    • Grenada
    • Guadeloupe
    • Guam
    • Guatemala
    • Guernsey
    • Guinea
    • Guinea-Bissau
    • Guyana
    • Haiti
    • Honduras
    • Hong Kong
    • Hungary
    • Iceland
    • India
    • Indonesia
    • Iran
    • Iraq
    • Ireland
    • Israel
    • Italy
    • Jamaica
    • Japan
    • Jersey
    • Jordan
    • Kazakhstan
    • Kenya
    • Kiribati
    • North Korea
    • South Korea
    • Kosovo
    • Kuwait
    • Kyrgyzstan
    • Laos
    • Latvia
    • Lebanon
    • Lesotho
    • Liberia
    • Libya
    • Liechtenstein
    • Lithuania
    • Luxembourg
    • Macau
    • Macedonia
    • Madagascar
    • Malawi
    • Malaysia
    • Maldives
    • Mali
    • Malta
    • Marshall Islands
    • Martinique
    • Mauritania
    • Mauritius
    • Mayotte
    • Mexico
    • Micronesia
    • Moldova
    • Monaco
    • Mongolia
    • Montenegro
    • Montserrat
    • Morocco
    • Mozambique
    • Myanmar
    • Nagorno-Karabakh
    • Namibia
    • Nauru
    • Nepal
    • Netherlands
    • Netherlands Antilles
    • New Caledonia
    • New Zealand
    • Nicaragua
    • Niger
    • Nigeria
    • Niue
    • Norfolk Island
    • Turkish Republic of Northern Cyprus
    • Northern Mariana
    • Norway
    • Oman
    • Pakistan
    • Palau
    • Palestine
    • Panama
    • Papua New Guinea
    • Paraguay
    • Peru
    • Philippines
    • Pitcairn Islands
    • Poland
    • Portugal
    • Puerto Rico
    • Qatar
    • Republic of the Congo
    • Romania
    • Russia
    • Rwanda
    • Saint Barthelemy
    • Saint Helena
    • Saint Kitts and Nevis
    • Saint Lucia
    • Saint Martin
    • Saint Pierre and Miquelon
    • Saint Vincent and the Grenadines
    • Samoa
    • San Marino
    • Sao Tome and Principe
    • Saudi Arabia
    • Senegal
    • Serbia
    • Seychelles
    • Sierra Leone
    • Singapore
    • Slovakia
    • Slovenia
    • Solomon Islands
    • Somalia
    • Somaliland
    • South Africa
    • South Ossetia
    • South Sudan
    • Spain
    • Sri Lanka
    • Sudan
    • Suriname
    • Svalbard
    • eSwatini
    • Sweden
    • Switzerland
    • Syria
    • Taiwan
    • Tajikistan
    • Tanzania
    • Thailand
    • Timor-Leste
    • Togo
    • Tokelau
    • Tonga
    • Transnistria Pridnestrovie
    • Trinidad and Tobago
    • Tristan da Cunha
    • Tunisia
    • Turkey
    • Turkmenistan
    • Turks and Caicos Islands
    • Tuvalu
    • Uganda
    • Ukraine
    • United Arab Emirates
    • United Kingdom
    • Uruguay
    • Uzbekistan
    • Vanuatu
    • Vatican City
    • Venezuela
    • Vietnam
    • British Virgin Islands
    • Isle of Man
    • US Virgin Islands
    • Wallis and Futuna
    • Western Sahara
    • Yemen
    • Zambia
    • Zimbabwe
    • Other
    Press
    Enter
  • 6
    Select from drop down list
    • Craighead
    • Mississippi
    • Greene
    • Poinsett
    • Other
    Press
    Enter
  • 7
    Press
    Enter
  • 8
    Email will be used to confirm appointment time and other information regarding COVID-19 testing.
    Press
    Enter
  • 9
    Select from drop down list
    • Unknown
    • Black or African American
    • White
    • Asian
    • American Indian or Alaska Native
    • Native Hawaiian or Other Pacific Islander
    • Other
    Press
    Enter
  • 10
    Select from drop down list
    • Unknown
    • Not Hispanic or Latino
    • Hispanic or Latino
    Press
    Enter
  • 11
    Type NONE if you do not have a primary care provider
    Press
    Enter
  • 12
    Press
    Enter
  • 13
    Press
    Enter
  • 14
    Press
    Enter
  • 15
    Press
    Enter
  • 16
    Please select a Test Appointment Time
    Press
    Enter
  • 17
    Please select one method of payment
    Press
    Enter
  • 18

    Consent and waiver: I consent the staff of Southern Pharmacy of Arkansas to administer the BD Veritor™ System for Rapid Detection of SARS-CoV-2 or the Assure COVID-19 IgG/IgM Rapid Test. I understand that any test results from either the BD Veritor™ System for Rapid Detection of SARS-CoV-2 or the Assure COVID-19 IgG/IgM Rapid Test will be reported to the Arkansas Department of Health using the information supplied on this form.  Any test results may also be shared with any Primary Care Provider listed on this form or patient may request test results to be shared with the provider of their choice.  I understand the both the BD Veritor™ System for Rapid Detection of SARS-CoV-2 or the Assure COVID-19 IgG/IgM Rapid Test have a possibility of producing false positive or false negative results.  Any treatment should be in coordination with a healthcare provider.  I also agree to follow the Center for Disease Control and Prevention (CDC) and Arkansas Deparment of Health guidelines regarding SARS-CoV-2. Links to Center for Disease Control and Prevention (CDC) and Arkansas Deparment of Health can be found here:  www.southernpharmacy.net/covid19resources.  I acknowledge that I have reviewed a copy of the Southern Pharmacy's privacy policies located here.  Southern Pharmacy may contact me via email and/or sms message using the information provided.  (Please sign on next screen)

     

    Press
    Enter
  • 19
    Clear
    Press
    Enter
  • 20
    Pick a Date
    Press
    Enter
  • 21
    prevnext( X )
        My Bag
        0
        My Bag
        Great Product Name
        $20
        Quantity:1
        Size:Small
        RemoveEdit
        Great Product Name
        $20
        Quantity:1
        Size:Small
        RemoveEdit
        Great Product Name
        $20
        Quantity:1
        Size:Small
        RemoveEdit
        Great Product Name
        $20
        Quantity:1
        Size:Small
        RemoveEdit
        ORDER SUMMARY
        TaxUSD
        SubtotalUSD
        Total costUSD
        • COVID-19 Antigen Test for Active InfectionCOVID-19 Antigen Test for Active Infection
          $60.00+Remove
          Back
        • COVID-19 Antibody Test for Previous InfectionCOVID-19 Antibody Test for Previous Infection
          $25.00+Remove
          Back
          Total cost $0.00
          COVID-19 Test
          loading smart payment buttons...
          The payment is ready! It will be completed once you submit the form.
          Press
          Enter
        • Should be Empty:
        hipaa badge
        Question Label
        1 of 21See AllGo Back
        close