RAPID ANTIGEN TEST

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Curbside Rapid Test Appointment (Call 732-526-4450 when outside)* This field is required.*Maximum of 4 family members per appointment slot to ensure the safety of our staff* Please call the pharmacy for any last minute openings. Thank you!
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Date and Time of Test Confirmation* This field is required.You must have an appointment TIME slot booked on previous screen. Please ensure it matches the previous screen.
Date
Month
Day
Year
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Hour
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05
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15
20
25
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Minutes
AM
AM
PM
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Due to high testing demand, we do not allow appointment cancellations. The Rapid test is non-refundable. 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 Pharmacy Emporium will not be held responsible for any representations.* This field is required.
YESNO
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Pharmacy PhoneFor your reference
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Patient Name* This field is required.Enter your information first and you will have an opportunity to add family member(s) further down.
First Name
Last Name
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Date of Birth* This field is required.MM-DD-YYYY
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Address
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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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.
12
Email *Required for results to be emailed to you
example@example.com
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ICD-10 Code* This field is required.Select whether symptomatic/suspected exposure OR asymptomatic/no suspected exposure
Z20.828 Contact with and suspected exposure to other viral communicable disease
Z11.52 Encounter for screening for COVID-19 (Asymptomatic)
14
Are you booking for more than one person?* This field is required.
YESNO
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How many people are you booking for?
2
3
4
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Second Person's Full Name.
First Name
Last Name
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Second Person's Date of BirthMM-DD-YYYY
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Second Person's AddressSkip if same as primary. Otherwise, include city, state and zip code
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Second Person's Phone Number Skip if same as primary
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Third Person's Full Name
First Name
Last Name
21
Third Person's Date of BirthMM-DD-YYYY
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Third Person's AddressSkip if same as primary. Otherwise, include city, state and zip code
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Third Person's Phone NumberSkip if same as primary
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Fourth Person's Full Name
First Name
Last Name
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Fourth Person's Date of BirthMM-DD-YYYY
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Fourth Person's AddressSkip if same as primary. Otherwise include city, state and zip code
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Fourth Person's Phone NumberSkip if same as primary
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Rapid COVID-19 Test Payment* This field is required.Please select correct number of tests when paying for multiple family members. We will provide an itemized receipt if you'd like to submit this to your insurance for possible reimbursement.
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ORDER SUMMARY
Total costUSD
In Store Curbside RAPID COVID-19 TestFlowFlex COVID-19 Antigen Test
$49.00+Edit
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