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Felicity Pharmacy Rapid COVID-19 Test Form
Felicity Pharmacy Rapid COVID-19 Test Form
      Please click "start" below to register-Please note this is NOT A FREE test and there is a $40.00Fee for the Rapid antigen test and $100.00 for Rapid PCR Test
Felicity Pharmacy Rapid COVID-19 Test Form
Language
  • English (US)
  • 1
    Please select an available 15-min time slot
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  • 2
    • NOT DETECTED FOR SARS-CoV-2/COVID-19
    • DETECTED/POSITIVE FOR SARS-CoV-2/COVID-19
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  • 3
    There is a fee associated with these tests
    • SARS-CoV-2 Rapid Antigen Test ($40.00)
    • SARS-CoV-2 RT-PCR Test/Mesa Accula ($100.00)
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  • 4
    /
    Pick a Date
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  • 5
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  • 6
    MM/DD/YYYY
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  • 7
    Male, Female, Transexual, Unknown
    • Male
    • Female
    • Transexual
    • Unknown
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  • 8
    Please Select One
    • Yes
    • No
    • Unknown
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  • 9
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  • 10
    Please Select
    • Please Select
    • NY
    • NJ
    • CT
    • PA
    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
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  • 11
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  • 12
    Required by the CDC
    • Black/African American
    • White
    • Asian
    • American Indian or Alaska Native
    • Native Hawaiian Or Pacific Islander
    • Unknown
    • Other
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  • 13
    Required by the CDC
    • Hispanic/Latino
    • Not Hispanic/Latino
    • Unknown
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  • 14
    Symptoms/ Reason for getting test
    Z03.818 Possible exposure to COVID 19, ruled out
    • Z03.818 Possible exposure to COVID 19, ruled out
    • Z11.59 Asymptomatic, no known exposure, results unknown or negative
    • R05 Cough
    • R06.02 Shortness of breath
    • R50.9 Fever unspecified
    • No Diagnosis, Testing for Travel Purposes
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  • 15
    By signing below you are giving the consent to be tested for COVID-19 via a mid-nasal swab. The testing is to comply with New York State Regulations. You will be provided with a copy of the test results and which COVID-19 test was used in the testing.  All standard HIPPA regulations will be followed. A copy of the Felicity Pharmacy’s HIPPA Policy Practices is available upon request. Test results as per New York State mandate will be reported to the appropriate administration of Felicity Pharmacy, the New York State ECLRS System and The New York Health Department
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