Doctor's Choice Pharmacy
COVID-19 Rapid Antigen Test Appointment
COVID-19 tests, 1 hour, $95 each (Credit/Debit Card Only)
IMPORTANT INFORMATION:
Rapid Antigen Test (Neg: 90%, Positive: 99% accurate)
This is NOT a PCR test required for travelling
Used for Healthcare workers and other workplace to get back to work.
DRIVE-UP ONLY. PLEASE CALL FROM YOUR CAR WHEN YOU ARRIVE.
Self Swab (we only collect samples and analyze)
Cancellation/Reschedule: $25 Fee
When
*
Date
-
Month
-
Day
Year
Date Picker Icon
Your Name
*
First Name
Last Name
Date of Birth (mm/dd/yyyy)
*
Age
*
Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Cell Phone Number
*
-
Area Code
Phone Number
Your Email
*
example@example.com
Ethnicity (select all that apply)
*
Asian
Hispanic/Latino
White
Black/African-American
American Indian/Alaskan Native
Native Hawaiian
Current Gender Identity
*
Male
Female
Prefer not to state
Sex at Birth
*
Male
Female
Non-Binary/X
Prefer not to answer
Sexual Orientation
*
Straight or Heterosexual
Gay or Lesbian
Bisexual
Prefer not to state
Living Situation
*
Private Residence
Hotel
Homeless
Long Term Care Facility
Occupation
*
Health Care Worker
Teacher
First Responder
Other
Back
Next
Have you had direct contact with someone who is confirmed to have COVID-19 within the past 14 days?
*
Yes
No
Do you have any Symptoms?
*
Yes
No
Do you have a cough, runny nose, sore throat, or congestion?
*
Yes
No
Date of onset
-
Month
-
Day
Year
Date
Do you have difficulty breathing or shortness of breath?
*
Yes
No
Hospitalization
*
Yes
No
Do you have a loss of taste or smell?
*
Yes
No
Do you have abdominal pain, diarrhea, nausea, or vomiting?
*
Yes
No
Do you have chills or fever of over 100 degrees?
*
Yes
No
Pre-existing Medical Conditions: select all that apply
Pregnancy
Diabetes
Hypertension
Cardiovascular Disease
Chronic Pulmonary Disease
Asthma
Chronic Renal Disease
Chronic Liver Disease
Immunocompromised
Neurologic Disability
None
Other
Informed Consent for COVID-19 Testing
I understand that Doctor's Choice Pharmacy is not acting as my medical provider. Testing does not replace treatment by my medical provider. I assume complete responsibility to take appropriate action with regards to my test results. I agree I will seek medical advice if needed. I also understand the potential for false positive or false negative test. I voluntarily agree to testing for COVID-19.
My Products
*
prev
next
( X )
COVID Antigen Test
$
95.00
15 Minute Rapid Antigen Test
Enter coupon
Apply
Total
$
0.00
Credit Card
First Name
Last Name
Credit Card Number
Security Code
Expiration Date
Postal Code
Submit
Should be Empty:
Now create your own Jotform - It's free!
Create your own Jotform