SHP Westchester COVID-19 Test Form

1
2
Select type of COVID-19 Test* This field is required.
Rapid Antigen Test Nasal Swab (Results within 10 minutes) - $65.00
Standard PCR Test Nasal Swab (Results in 48 hours) - FREE (Exceptions may apply)
Rapid COVID-19 PCR Nasal Swab Test (Results within 15 minutes)- $180
3
Appointment Request* This field is required.Please arrive promptly at your scheduled time.
4
Appointment Request* This field is required.Please arrive promptly at your scheduled time.
5
Do you have medical coverage such as individual, employer-sponsored, Medicare or Medicaid?* This field is required.
YESNO
6
Due to High Testing Demand, We do not allow appointment cancellations. 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 Super Health Pharmacy will not be held responsible for any representations.* This field is required.
YESNO
7
Date of Test* This field is required.Testing Starts At 10AM Daily! You must have an appointment TIME slot booked on previous screen unless otherwise authorized by pharmacy personnel.
Date
Month
Day
Year
8
Patient Name* This field is required.
First Name
Middle Name
Last Name
9
Middle Initial
10
Date of Birth* This field is required.MM/DD/YYYY
11
Is the patient a minor?* This field is required.
YESNO
12
Parent/Guardian* This field is required.
First Name
Last Name
Relationship to Patient
13
Patient Address * This field is required.
14
City* This field is required.
15
State* This field is required.
16
ZIP Code* This field is required.
17
Cell Phone* This field is required.
18
Gender* This field is required.
19
Race* This field is required.Required By CDC
20
Ethnicity* This field is required.Required By CDC
21
ICD-10 Code* This field is required.
Z20.828 Contact with and suspected exposure to other viral communicable disease
Z11.59 Asymptomatic, no known exposure, results unknown or negative
22
Email* This field is required.
example@example.com
23
Picture of Government Issued IDDrivers License, Passport, Etc
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
24
Secure Payment Portal* This field is required.Payment is nonrefundable; Items will be delivered curbside during testing
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
Total costUSD
Rapid COVID-19 TEST (RT-PCR)This is the most accurate Rapid COVID-19 Test accepted by most airlines.
$180.00+Remove
Back
Rapid COVID-19 TEST (Antigen)Rapid COVID-19 TEST
$65.00+Remove
Back
Total cost $0.00
Credit Card
First Name
Last Name
Credit Card Number
Security Code
Expiration Date
Postal Code
25
Thank you for making an appointment for Standard PCR Test. When you submit, you will be redirected to the lab's webpage, so you can be enrolled with them. Please make sure you are enrolled with the lab, as your test WILL become invalid if you are not enrolled.

Please bring your government-issued ID and insurance cards with you to the testing location.

Our testing location is: 1 Croton Point Ave Croton, NY 10520. Please call 914-774-8425 at the time of appointment for curbside testing. Thank you!
Should be Empty:

Save your progress

Save your progress

Your form submission has been saved as a draft.

Save your progress

Your form submission has been saved as a draft.