Rapid COVID-19 Test - Direct Pay
Get your results within 24 hours
Choose Your Test
20 minutes Rapid Antibody Test (Finger prick)
20 minutes Rapid Antigen Test (Nasal Swab)
2 Hour Same Day PCR Test
Name
First Name
Last Name
Date Of Birth
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Month
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Day
Year
Date
Gender
Male
Female
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Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
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Email
example@example.com
Appointment
You agree to participate in the COVID-19 Testing offered by Park Ridge Pharmacy. By signing this Consent Form, you hereby acknowledge, understand, and agree that: • You agree to participate in the COVID-19 Testing Program and consent to obtaining testing for the COVID-19 virus and/or related antibodies from Park Ridge Pharmacy. • You have been informed about the purpose, process, and possible benefits and risks of COVID-19 testing and have had the opportunity to have your questions answered by Park Ridge Pharmacy team member. • You authorize the release of any and/or all medical information necessary for claim submission of services from the insurance carriers or other payers to who claims have been or are being submitted. You authorize for Park Ridge Pharmacy to be paid directly to for COVID-19 testing. • You authorize Park Ridge Pharmacy to disclose the results of your COVID-19 testing to your physician identified above. You further acknowledge that you received a copy of Park Ridge Pharmacy’s Notice of Privacy Practices. Except as permitted by this Consent Form or the Notice of Privacy Practices, or otherwise permitted or required by law, your personal health information will not be shared with your physician or any other third party without your consent. • You have the right to decline COVID-19 testing from Park Ridge Pharmacy and you are free to obtain health care services and advice from any other health care provider of your choice. • You understand Park Ridge Pharmacy does not guarantee the turnaround time of tests for the COVID-19 virus and/or related antibodies testing. You hereby agree to hold Park Ridge Pharmacy and its providers harmless from any and all liabilities and claims for any delay or consequences due to the delay in results. • You understand Park Ridge Pharmacy does not guarantee the coverage of any test under insurance and you may be billed for any testing considered not medically indicated. • You understand that, as with any medical test, there is a possibility that a false positive or false negative test result may occur, and Park Ridge Pharmacy does not guarantee the accuracy of the COVID-19 testing. You hereby agree to hold Park Ridge Pharmacy and its providers harmless from any and all liabilities and claims relating to the inaccuracy of the COVID-19 testing provided pursuant to this Consent Form. • You have read and fully understand this Consent Form and you are signing it freely and voluntarily.
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