COVID-19 Test Consent Form
Name
*
First Name
Middle Name
Last Name
Birth Date
*
-
Month
-
Day
Year
Date
Gender
Female
Male
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Questions for person receiving testing:
Are you sick today or have you been sick in the last 24 hours?
*
Yes
No
If you answered yes to the question above, please check the symptoms that apply
Loss of taste or smell
High fever
Difficulty in breathing
Body aches
Runny nose
Diarrhea
Cough
Persistant pain or pressure on chest
Nasal congestion
Sore throat
Other
Are you CURRENTLY in an isolation or quarantine period due to COVID-19?
*
Yes
No
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Payment
*
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COVID-19 Rapid PCR
Nasal swab test for molecular based testing. This test is more sensitive than the antigen tests. Suggested for asymptomatic people and perfect for travel requirements!
$
149
COVID-19 Antigen Test
Nasal swab test for detecting the COVID-19 virus in the nose. Suggested for symptomatic people or asymptomatic people (less recommended than PCR due to possibility of false negative).
$
Free
Credit Card
Consent for person receiving testing:
*
I authorize the disclosure of my test results and any follow-up test results to the county and state public health departments or to any other governmental entity as required by law, the ordering provider, or my employer. I understand that a positive test result is an indication that I am infected with the virus that causes COVID-19 and I must isolate myself consistent with guidance from the local and state health departments in an effort to avoid infecting others. I understand that, as with any medical test, there is the potential for false positive or negative test results to occur. I understand if I have any unusual symptoms after testing, it is my responsibility to seek medical attention. I, the undersigned, have been informed about the test purpose, procedure, benefits, and risks. I have been given the opportunity to ask questions before I sign, and I have been told that I can ask questions at any time. I voluntarily agree to be tested for COVID-19, including any follow-up testing.
For state funded PCR testing:
I have or will complete the additional requirement paperwork found at https://covidconnect2.wi.gov/#/login before coming to Tomahawk Pharmacy for my sample collection.
Confirmed State PCR Chosen
State PCR
Confirmed Rapid Antigen Chosen
*
Rapid Antigen
Confirmed Antigen + Flu Chosen
Rapid Antigen + Flu
Confirmed Rapid PCR Test Chosen
Rapid PCR
Confirmed Antibody Test Chosen
Antibody
How would you like your results delivered? (check all that apply)
*
Phone call
Email
I'll wait for a paper copy
Signature
*
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