COVID-19 Rapid Antigen Test + Appt

COVID-19 Rapid Testing

* Please fill out the required details below. We offer antigen testing for current infection. All testing is conducted curbside at 38th Street Pharmacy at 711 W 38th Street C-3 Austin, TX 78705. Appointments are non-refundable and cannot be cancelled or rescheduled.
Section I. Personal Information
Patient's Full Name: *

FirstName LastName
Date of Birth: *

Month Day Year
Patient Cell Phone Number *
Please enter a valid phone number. Only enter numbers no () or dashes.
Primary Phone Number *
Please enter a valid phone number. Only enter numbers no () or dashes.
Address *

AddressOne

AddressTwo

City StateCode

Zip Country
Email *
example@example.com
Gender at birth: (M: Male, F: Female, U: Other) *

M F U
Ethnicity: *

Hispanic or Latino Non Hispanic/Latino Unknown
Race: *

Black or African American American Indian or Alaska Native Asian White Native Hawaiian or Other Pacific Islander Other
County you live in (for example Travis, Hays, etc.) *
CountyOfResidence
Section II. Appointment Scheduler
Please pick a day and time for your COVID-19 test: *
Section III. Signatures

I hereby give my consent to 38th Street Pharmacy to receive a COVID-19 test. I understand that no test is 100% accurate, and there is a chance that the results may not accurately reflect my COVID-19 status. I also understand that due to the sensitivity and availability of this test, I am not entitiled to a refund under any circumstance. I am expected to arrive on time to my appointment, and I understand that my test may not be rescheduled. I consent to having my results send via email provided above.

Price: $95 USD

If you have questions, please call us at 512-458-3784.

This form is HIPAA compliant and secure. Any and all information you enter will only be viewed by the staff of 38th Street Pharmacy.
Signature of Person to Receive COVID-19 Rapid Antigen Test *

Clear
By clicking the "Submit" button below, you certify that the above information is correct and accurate to the best of your knowledge. All information is confidential and is accessed only via a secure, encrypted interface.
Should be Empty:

Now create your own JotForm - It's free! Create your own JotForm

COVID-19 Rapid Testing