SHP Westchester COVID-19 Form

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Select type of COVID-19 Test* This field is required.Premium Concierge Service!
Rapid Covid-19 Antigen Test Nasal Swab (Results within 10 minutes) $120 (Appointment required)
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Appointment Request* This field is required.Please arrive promptly at your scheduled time.
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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
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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
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Patient Name* This field is required.
First Name
Last Name
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Middle Initial
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Date of Birth* This field is required.MM-DD-YYYY
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Patient Address * This field is required.
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City* This field is required.
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State* This field is required.
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ZIP Code* This field is required.
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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.
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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
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Email *Needed if you need the results emailed to you
example@example.com
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Picture of Government Issued IDDrivers License, Passport, Etc
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
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Secure Payment Portal* This field is required.Payment is nonrefundable; Items will be delivered curbside during testing
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Size:Small
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Size:Small
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ORDER SUMMARY
Total costUSD
Rapid COVID-19 TESTFastest way to get in and out is by paying online
$120.00+
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Total cost $0.00
Credit Card
First Name
Last Name
Credit Card Number
Security Code
Expiration Date
Postal Code
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