COVID-19 Rapid Test Consent and Appt Form

COVID-19 Testing

Appointment & Consent Form
Rapid COVID-19 Antigent Test: $89.99

Rapid COVID-19 Antibody Test: $49.99

All results available in 15 minutes!
Select a 15-minute time slot for your COVID-19 Testing Appointment *
Patient Name *

First name Middle name Last name
Date of birth (MM/DD/YYYY) *

Month Day Year
Date
Age *
Address *

Street Address (and unit/apt # if applicable)

Street Address Line 2

City

Zip code
State *
You may choose a different option if your State is different
Phone Number *
Sex at birth *

Female Male Neither/Other Unknown
Select the most appropriate status below regarding pregnancy *

Pregnant Postpartum Unknown Neither pregnant nor postpartum
Race (select all that apply) *

Unknown American Indian or Alaska Native Asian Black or African American Native Hawaiian or other Pacific Islander White Other race (specify)
Ethnicity *

Hispanic or Latino Not Hispanic or Latino Unknown
Do you have any symptoms? *

Yes No Unknown
List your symptoms (if applicable)

Fever or chills Cough Shortness of breath or difficulty breathing Fatigue Muscle or body aches Headache New loss of taste or smell Sore throat Congestion or runny nose Nausea or vomiting Diarrhea
In addition to a phone call about your test results, please select your preference for an text notification.

I would like to receive my test results via an secured text from Sachse Discount Pharmacy that is HIPAA Compliant. I DO NOT want to receive my test results via an secured text from Sachse Discount Pharmacy that is HIPAA Compliant.
Signature *

Clear
What is the patient's affiliation to the facility

Resident of Senior Living Facility or LTC Facility Healthcare Worker Student Other
Should be Empty:

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COVID-19 Testing