COVID-19 Testing Registration Form

COVID-19 Testing Registration Form
Patient Name

First NameMiddle NameLast NameSuffix
Date of Birth

MonthDayYear
Date
Date Submitted

MonthDayYear
Date
Test Result

PositiveNegativeIndeterminate
Test Type

BD Veritor SARS-2 Antigen TestQuidel QuickVue SARS-2 Antigen TestAccula SARS-CoV-2 Test PCR TestIndicaid SARS-2 Antigen TestInfluenza A&B Rapid TestStrep A Rapid TestFlowFlex Covid-19 Antigen TestOther
Specimen Collection Date

MonthDayYear
Date
Specimen Collected By

Michael MunizChristine TorralbaMoses VentoMathew Vasquez
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Gender

FemaleMale
Race

WhiteBlackAsianOtherUnknown
Ethnicity

HispanicNot HispanicUnknown
Age
Patients Phone Number
Patient Email
example@example.com
Symptom Onset Date

MonthDayYear
Date
Have you traveled recently?

Travel: YesNo
Date of Travel

MonthDayYear
Date
If yes, where
Reason for Travel
Available Test*
prevnext( X )
COVID-19 Rapid Antigen Test (Same-Day Results)Rapid Antigen Test,
$50.00



COVID-19 Rapid PCR Test (Same Day Result)
$150.00



Indicaid (Same-Day Results)Rapid Antigen Test
$50.00



Influenza A&B Nasal Swab Rapid
$45.00



Strep A Throat Swab Rapid
$45.00



Total

$0.00
Consent for Testing:

I understand and agree:

I am consenting to receiving a point-of-care test with NuRx Pharmacy.
No test is 100% accurate, and there is a chance that the results of the test may or may not accurately reflect my diagnostic status.
I do not hold NuRx Pharmacy LLC or any employee or other representative of NuRx Pharmacy responsible for any consequence of a positive, negative, or inconclusive result.
Due to the nature of point-of-care testing, there is a risk that I may be exposed to or infected by proceeding with my scheduled testing and hereby fully assume all risks which include without limitation, the need for additional testing, a positive diagnosis, required quarantine or self-isolation, hospitalization, treatment in an intesive care unit and intubation or ventilation support, death, and/or other medical complications.
NuRx Pharmacy may have an obligation to report test results to governmental or other public health authorities pursuant to applicable law and regulations and I hereby consent to any such reporting by NuRx Pharmacy.
I acknowledge and agree to having my test results sent to me via text message. And also over email, if I request the official PDF result. I understand that this is considered Protected Health Information (PHI), and authorize NuRx Pharmacy to send it.
In the event that my employer pays (whether directly or indirectly) for my test, then I hereby consent to NuRx Pharmacy disclosing the results of my test to my employer.
Under no circumstance am I entitled to a refund.
I am expected to arrive on-time to my appointment.
If I am late or miss my appointment, I understand that my test may not be rescheduled and I am not entitled to a refund.
Printed Name
Signature

Clear
Date*

MonthDayYear
Date
Hour MinutesAM/PM Option
Social Security Number
Drivers License and/Or Insurance Card

Cancelof
Billed

Yes
Notifiable Condition Reporting

ClinicalSerologyCulture/PCRBiopsy/SmearOther
Submitting (Reporting) Facility
Address
Name of Person Submitting Report
Title/Department
Phone Number
Yes No

YesVaccinated Against Varicella:Number of Doses Received: 1
Dr Office Phone
( )
Notifiable Condition
Date of Notifiable Condition Dx

MonthDayYear
Date
2
Admit Date

MonthDayYear
Date
Discharge Date

MonthDayYear
Date
Name of Diagnosing Physician
Physician’s Address: ( ) Clinic ( ) Hospital ( ) Office
Chickenpox (varicella) reporting only:

NoYes No2
1
Additional Information
additional page(s)
Full Name
Should be Empty:

COVID-19 Testing Registration Form

Consent for Testing: