Coronavirus testing Scheduler(Age 3yr+)

Coronavirus testing Scheduler(Age 3yr+)
My Products (Do not select more than 1 test per appointment) *
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RT-PCR Results in 1-2 hours *$30 cancellation fee applies * Please note this test is available only until 2 hours before pharmacy closing time. M-F 10-4pm, Sat 10-12pm. Since calendar cannot be changed for 1 test, we hope you read this and understand the limitations.
$ 160.00 Quantity

PCR Test Results 24 hours or less *$30 cancellation fee applies **Results in 24hr. ONLY during business days M-F. Swabs taken Saturday, the results wont be available until Monday 6pm. *** For less than 24hr results, the swab has to be done before 12noon. *Lab is closed Saturday and Sunday. No results provided Saturday or Sunday with this type of service. Swabs taken Friday-Sun are processed Monday by 6pm.
$ 140.00 Quantity

PCR test 48 hours result *$25 cancellation fee applies -Best for those who need result in 72hrs prior to departure -Results in 48 Business hours or less. Swab taken before 11:30am M-T, results by next day 6pm, swab taken after 11:30am results given day after by 6pm. -Lab is closed on weekends. Sample collected on weekend is delivered Monday evening for processing with results released on Tuesday.
$ 120.00 Quantity

Rapid Antigen Coronavirus Test (15-30min results) *$10 cancellation fee applies *Best to detect active COVID-19 disease *Results in 16-30mins.
$ 40.00 Quantity
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$ 0.00
Appointment *
Patient Name *

First Name Last Name
Date of Birth *

Month Day Year
Date
Phone Number *
Please enter a valid phone number.
Patient's Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Gender at Birth *
Race *
Ethnicity
Allergies
Email to Communicate *
example@example.com
ID Card Number (Driver License or Passport)
Remember to bring Original ID, photocopies or photos not accepted
State/Country of Issue for ID entered above
Expiration date of ID

Month Day Year
Date
Do you have any symptoms of COVID or any illness? *

Yes No
Required SARS CoV2 Survey for all tests (check all that apply): *

This is my first COVID test I have been in an enclosed space with greater than 8 people with no social distancing I have been in contact with someone with COVID-19 in past 14 days I have been advised to get COVID-19 test prior to medical procedure I have tested positive for COVID antigen test in past I reside in a congregate care facility I am pregnant I am a smoker I am in ICU I have traveled out of state or country in last 14 days I am currently hospitalized I have tested positive for COVID antibody test in past I am employed in healthcare setting None Apply
Consents *

I hereby grant permission to Crofton Pharmacy, its subsidiaries and affiliates, and each of their agents, employees, officers, directors, servants, successors, heirs, executors, and administrators, (collectively, "CPH Corp") to perform certain screening tests as set forth below at my direction, which may include obtaining specimens of mucus by nasal, nasopharyngeal or oropharyngeal swab or blood by venipuncture or finger stick. I authorize CPH Corp to obtain these screening results and provide them to me via phone, email or mail. I agree to pay for the tests in full at the time of service. I understand that the testing has not been ordered by a physician and is being done for my own use and not for medical diagnostic or treatment purposes. I understand that the test results will not be forwarded to any medical professional for diagnosis of any medical condition. It is my responsibility to share the test results with my physician at my sole option. I, alone am responsible for obtaining medical information, treatment or services from doctor or other health care provide din relation to test results. I understand the state may use my information and contact me for any purpose deemed necessary. I understand these tests have not been cleared or approved by the FDA and all these tests have been authorized by FDA under EUA's for use by authorized laboratories/Pharmacy. I understand these tests have not been cleared or approved by the FDA and all these tests have been authorized by FDA under EUA's for use by authorized laboratories/Pharmacy. I have been provided with, read and understood the patient handouts or factsheets for these tests. I understand the risks, limitations, nature of these tests. I understand that PCR test samples need to be transported/shipped to laboratory for processing. I understand that if the sample is lost, destroyed, damaged during shipping or handling, CPH Corp is only liable to return the fee paid for the test and nothing more. I hereby and for my heirs, executors, administrators, successors and assigns release, acquit and forever discharge CPH Corp, of and from any and all claims, actions, causes of action, demands, rights, damages, injuries and property damage and the consequences thereof resulting or to results from the testing or delay in obtaining results of testing due to shipping or any other reasons. I acknowledge that I have read this release form prior to signing it and that I understand its contents. I understand and agree that I will not be able to sue CPH Corp for any injury or property damage I may suffer as a result of the testing. I HEREBY CERTIFY THAT I HAVE READ THE ABOVE ACKNOWLEDGEMENT AND HAVE HAD AN OPPORTUNITY TO ASK QUESTIONS ABOUT ITS CONTENTS. BY SIGNING BELOW, I CONSENT TO UNDERGO THE SELF-DIRECTED LABORATORY TESTING UN THE CONTDITIONS SET FORTH HEREIN.
Patient/Guardian Signature for consents *

Clear
Date *

Month Day Year
Date

Payment Methods

Debit or Credit Card

First Name	Last Name
Credit Card Number	Security Code
Card Expiration

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