Pharmacy Town RAPID ANTIGEN COVID-19 Form

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Please read the following statement in it's entirety: Due to high testing demand, we do not allow appointment cancellations. *Tests are $89 and non-refundable.* These are RAPID ANTIGEN TESTS (NOT THE RT-PCR TEST). Please verify with your end user if they will accept a RAPID ANTIGEN COVID-19 Test as clearance, if this test is intended for such purpose: work, travel, nursing home, hospital, etc. By signing your name, you agree to our terms that PHARMACY TOWN LLC will not be held responsible for any representations.* This field is required.
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Currently Available AppointmentsPlease call the pharmacy 732-493-5100 for any last minute openings. Thank You
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Appointment
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Date and Time of Test Confirmation* This field is required.You must have an appointment TIME slot booked on the previous page. Please enter it here
Date
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Year
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Minutes
PM
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PM
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Patient Name* This field is required.
First Name
Middle Initial
Last Name
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Gender* This field is required.
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Date of Birth* This field is required.MM-DD-YYYY
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Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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
Curaçao
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
Country
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Cell Phone* This field is required.
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Email* This field is required.Needed if you need the results emailed to you
example@example.com
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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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Insured's Name
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COVID 19 (SARS CoV 2 Assay) via Nasal Swab* This field is required.
RAPID ANTIGEN COVID 19 (SARS CoV 2 Assay) via Nasal Swab
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ICD-10 Code* This field is required.PLEASE STAY IN YOUR CAR AND PULL UP TO THE FRONT OF THE STORE IF YOU ARE SYPTOMATIC OR HAVE BEEN EXPOSED TO SOMEONE WITH COVID. DO NOT COME INSIDE.
Z20.828 Contact with and suspected exposure to other viral communicable disease (DO NOT COME INSIDE, STAY IN YOUR CAR)
Z11.59 Asymptomatic, no known exposure, results unknown or negative
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Payment* This field is required.
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ORDER SUMMARY
Total costUSD
COVID-19 RAPID ANTIGEN TESTThis is NON-REFUNDABLE. If you cancel or no-show, you will not receive a refund.
$89.00+Edit
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Total cost $0.00
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First Name
Last Name
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Invoice ID
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Results under FDA approved under EUA category, ACCESS BIO TEST for detection of SARS-CoV-2
NEGATIVE
POSITIVE
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