COVID-19 Antigen Test Consent Form
Date of Birth
Street Address Line 2
State / Province
Postal / Zip Code
Primary Care Provider
How would you best describe your race? Please select all that apply. If you would prefer not to answer this question, you may leave it blank.
American Indian or Alaskan Native
Black or African American
Native Hawaiian or other Pacific Islander
How would you best describe your ethnicity? Please select all that apply. If you would prefer not to answer this question, you may leave it blank.
Hispanic or Latino
Not Hispanic or Latino
Do you work or live in a healthcare setting?
Underlying Conditions: Please select all that apply
Chronic Obstructive Pulmonary Disease (COPD)
High blood pressure
Chronic Liver Disease
Chronic Kidney Disease
Have you had a COVID-19 vaccine?
Have you had direct exposure to COVID-19?
If yes, how many days ago were you exposed to COVID-19?
What symptoms are you experiencing now? Please select all that apply.
Fever or chills
Shortness of breath
Muscle or body aches
New loss of taste or smell
Sore throat/ Hoarsness
Congestion or runny nose
Nausea or vomiting
For how many days have you been experiencing symptoms?
By signing below, I give consent to Bay Street Pharmacy to send my testing results to the Florida Department of Health. Additionally, I signify that I agree to allow Bay Street Pharmacy to administer the COVID-19 test for a fee.
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