COVID Test Consent Form - Rose Hill Pharmacy

COVID Test Consent Form

We currently offering PCR TEST again at $0. You will have the results back within 24-48 hours. Due to supply issues, we have RAPID TEST while supplies last.
If you are not able to click on a timeslot for a particular date, that means all appointments are FULL. Please DO NOT call the pharmacy, simply choose another date and time. We appreciate your understanding as call volume only delays services and we are doing our best during this busy time.
Section I. Personal Information
Patient's Full Name *

First NameMiddle NameLast Name
Mother's Maiden Name *
Date of Birth:*

MonthDayYear
Age:*
Phone Number:*
Email:*
Add up to 1 additional family members ( full name and date of birth). You have to make additional appointment for 2 additional people or more.
Enter a FOUR digit PIN if requesting online access for saliva test:
Gender:*

MaleFemale
Are you currently pregnant?*

YesNoUnsure
Ethnicity:*

Hispanic or LatinoNon Hispanic/LatinoUnknownPrefer not to answer
Race:*

African AmericanAmerican IndianAsianCaucasianNative Hawaiian/Other Pacific IslanderPrefer not to answer
Address:*

Street Address Line 2
Primary Care Doctor:*
Doctor City/State:*
My preferred test is:*

PCR Test ( PREVERED) (saliva tests - results in 24-48 hours) PLEASE DO NOT EAT OR DRINK 30 minutes before taking the test. Note tests done after 1:30 will get results back in 48hrs.RAPID TEST (nasal swab - results in 15-20 min)
Is this your first Covid test?*

YesNo
Do you work in a healthcare setting?*

YesNo
Have you had a COVID vaccine?*

Yes, PfizerYes, ModernaYes, Johnson&JohnsonYes, but only one of two doses of mRNA vaccine (Moderna/Pfizer)No
If you have received a COVID vaccine please list the date of your last dose *

MonthDayYear
Date
Have you had an exposure to COVID-19?*

YesNoUnsure
Approximately how many days ago were you exposed?
What symptoms are you experiencing now? Please check all that apply.*

Fever or ChillsCoughShortness of breathFatigueMuscle or body achesHeadacheNew loss of taste or smellSore throat/hoarsenessNausea or vomitingDiarrheaCongestion or runny noseNo Symptoms
Appointment*
Pharmacists can now prescribe Paxlovid (antiviral therapy) for COVID-19. If you test positive would you interested in being assessed for treatment?*

YesNo
Graves Drug is unable to bill insurance for Pharmacist assessment and prescribing of Paxlovid. While the test and medication are at no charge to the patient the assessment will have a $45 fee.*

I agree to pay $45 for the assessment.I prefer to see my physician for assessment.
Please answer a few screening questions to ensure you qualify for the assessment. Select all that apply.*

I am 18 years old or older.I have an underlying medical condition or over the age of 65.I do not have severe renal disease (eGFR less than 30)I do not have severe chronic liver disease.I have had COVID symptoms for 5 days or less.
Please select any medications you take from the following list. Select all that apply.*

alfuzosinamiodaroneapalutamidecarbamazepineclozapinedihydroergotaminedronedaroneeletriptaneplerenoneergotaminefinerenoneflecainideflibanserinivabradinelomitapidelovastatinlumacaftor/ivacaftorlurasidonemethylergonovinemidazolamnaloxegolpethidinephenobarbitalphenytoinpimozideprimidonepropafenonequinidineranolazinerifampinSt. John’s WortsildenafilsilodosinsimvastatintolvaptantriazolamubrogepantvoclosporinNone of the Above
Section IV. Signature

By signing this form, I give consent for Derby Drug to send my testing results to the Kansas State Department of Health and Welfare.
Signature of Person to Receive COVID test (or Signature of Parent/Guardian if Patient is < 18 yo)*

Clear
Name Parent/Guardian

First NameLast Name
Date of Birth of Parent/Guardian

MonthDayYear
Date
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.
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