COVID 19 Antigen Test Consent Form

OUT OF STOCK

Buena Vista Drug is currently out of rapid COVID tests.

We expect to receive more tests in the coming days. If you would still like to receive a test when they come in please continue to complete the form and we will call you when they are available.
Rapid COVID-19 Antigen Test Screening Form
Please select how you would like to receive the Rapid COVID Antigen Test

Schedule an appointment to receive a Rapid COVID Antigen Test in your car. Ensure that your appointment is scheduled no sooner than 1 hour after submitting your form. Rapid COVID Antigen Test without an appointment. Complete your paperwork online, prior to your arrival. Call us when you arrive and a pharmacist will come outside to administer the test within 15 minutes of your arrival.
Rapid COVID Antigen Tests are by appointment. You will be asked to schedule your appointment at the end of this form.

Appointments must be booked at least 5 minutes in advance.
Appointment

Patient Name *

First Name Middle Name Last Name
Date of Birth *

Month Day Year
Date
Age *
Gender *

Female Male
Race/Ethnicity *

Caucasian/White African American Hispanic Asian American Indian Pacific Islander Other
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Patient Phone Number *
Email
example@example.com
Primary Care Provider (PCP) Name

First Name Last Name
Please check below if any of these apply to you. If so you are considered HIGH RISK *

Over 65 Cancer Chronic Kidney Disease COPD Smoker Heart Condition Immunocompromised Obesity Sickle Cell Disease Type 2 Diabetes I have none of these conditions
Current Symptoms

For Patients: The following questions will help us determine the severity of your illness and recommendations we can make. If a question is not clear, please ask us to explain it.
Please check below if any of these apply to you. *

Fever >100.4 F Sore throat Runny nose Stuffy nose Muscle aches Shortness of breath/difficulty breathing New loss of taste or smell Cough Headache Fatigue (tiredness) Vomiting Diarrhea Chills NO Symptoms
How long have you had symptoms?
What actions have you taken to date?
Assessment
Within the past 14 days, have you been in close physical contact (6 feet or closer for a cumulative total of 15 minutes) with:
Anyone who is known to have laboratory-confirmed COVID-19? *

Yes No
OR
Anyone who has any symptoms consistent with COVID-19? *

Yes No
Are you isolating or quarantining because you may have been exposed to anyone with COVID-19 or are you worried that you may be sick with COVID-19? *

Yes No
Are you currently waiting on the results of a COVID-19 test? *

Yes No
Consent to Testing
I hereby authorize the pharmacist from Buena Vista Drug to perform a COVID-19 Rapid Antigen Test. I authorize the pharmacists to maintain a copy of this signed form. I indemnify the organizing body and all persons connected with them from any and all claims that may result from my voluntary participation in the tests. I understand that my results will be submitted to the Colorado Department of Health, as required by law. By signing below, I signify that I agree to allow those pharmacists affiliated with the pharmacy named above to administer the COVID-19 test for a fee of $75.00. I understand that my insurance might not reimburse the fee for the test and hold the pharmacy and pharmacist harmless for any fees not reimbursed. I understand the test that I am receiving is a rapid diagnostic test using antigens. Antigen tests look for viral proteins, which are highly specific, meaning that if you test positive, you are very likely infected. However, there is a higher chance of false negative with antigen tests, which means that a negative result cannot definitively rule out an active infection. If you have a negative result on an antigen test but have a recent exposure to COVID, or are displaying many of the symptoms, you may wish to take a PCR test to confirm your result. A PCR test looks for the presence of the virus' genetic material. PCR tests are highly accurate, but can take days to a week to get the results. The antigen test that you are receiving today is most accurate if you are symptomatic and within the first five days of symptoms. If you are testing to meet a travel requirement, it is your responsibility to determine if you are required to take a PCR test or an antigen test. The test you are receiving today is an antigen test.
To protect patient privacy, any data that state or juridictional health departments send to CDC will be deidentified and will not include some patient-level information. The deidentified data shared with CDC will contribute to understanding COVID-19's impact, positivity trends, testing coverage, and will help identify supply chain issues for reagents and other materials.
I understand if my results are positive I should follow-up with my primary care provider. *

Yes
Form completed by *

First Name Last Name
Representative name (if applicable)

First Name Last Name
Signature of Person Receiving the Testing (or Parent/Guardian of person < 18 years old)

Clear
Pharmacy Use Only

Do no complete the below questions
Name / NPI Pharmacist (Signature)

Lucas Smith, 1609283837 Lauren Gover, 1205345865
Temperature (F) *
BD Veritor SARS-CoV2 Rapid Antigen TEST RESULT *

POSITIVE NEGATIVE
BD Veritor SARS-CoV2 Lot *
BD Veritor SARS-CoV2 Exp *
BP
Pulse
Drug Allergies
Current Medications
Should be Empty:

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Rapid COVID-19 Antigen Test Screening Form

Current Symptoms

Assessment

Consent to Testing

Pharmacy Use Only