Clinical Services Appointment Form
Name
First Name
Middle Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
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
What services are you interested in? (additional cost may apply)
Medicare Plan Selection
Medication Counseling
Covid-19/Flu A&B Antigen Testing (We do ask you to please pay using the online payment option to minimize contact)
Strep Testing
Uti Testing
Blood sugar/A1c Testing & Consult
Cholesterol Level Testing & Consult
Blood Pressure Check & Consult
Hormone Replacement Consult
Other
If you selected "Other" please describe what service we can provide you.
Appointment
I authorize a represenative of Little Drug to conduct specimen collection, testing and analysis according to routine point of care testing protocols and procedures.
I authoize Little Drug to disclose my test results to the appropriate healthcare officials, including but not limited to the Department of Health, Physicians, Etc. For the purpose of further treatment.
I understand that any counsel provided by a representative of Little Drug is for my benefit. I also understand that I may ask questions at anytime if desired.
I acknowledge that the results of a Covid Test will require I take appropriate measures to prevent transmission of the disease per CDC Guidelines, including self-isolation, untill my condition is resolved.
I understand that upon a Positive result of any point of care test, it is my responsibility to seek further treatment from a medical provider of my choice, and I will seek emergency medical treatment if needed.
I understand that timing of point of care tests are important and I have been made aware that testing too soon or too late can produce false positives or false negatives.
I have been informed of all the purpose, procedures, and benefits/concerns with the appropriate test. I have been given the opportunity to ask all questions before and after the test at any time.
I authorize a representative of Little Drug to bill by Commercial Insurance, State Medicaid, or Medicare for appropriate services. I also agree to pay all fees and or copayments that are incurred for services provided.
I voluntarily agree to be tested by a representative of Little Drug.
Signature
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Date
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Month
-
Day
Year
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Hour Minutes
AM
PM
AM/PM Option
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