PCR COVID-19 Test Scheduling and Consent Form
Email
example@example.com
Select a 30 minute time slot for your COVID-19 Test Appointment
*
Vehicle description
Test will be conducted in vehicle. Please do not enter the pharmacy.
Patient First Name
*
Patient Middle Name/Initial
Patient Last Name
*
Sex at birth
*
Please Select
Female
Male
Neither/Other
Unknown
Date of Birth
*
-
Month
-
Day
Year
Date
Patient Street Address
*
Patient City
*
Patient State
*
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
NORTH CAROLINA
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
You may choose a different option if your State is different
Patient Zip Code
*
Patient Phone Number
*
Please enter a valid phone number.
Facility Name
Please Select
Medicap Pharmacy 8396
Facility Address
Please Select
1851 Virginia Ave
Harrisonburg, VA 22802
Submitted Date
-
Month
-
Day
Year
Date
Facility State
Please Select
Virginia
Facility Zip Code
Please Select
22802
Facility County
Please Select
Rockingham
Facility Phone
Please Select
540-434-7455
Type of Facility
Please Select
Pharmacy
Ordering Provider Name
Please Select
Melvin Anderson
Ordering Provider Phone
Please Select
540-434-7455
NPI
Please Select
1316540628
Ordering Provider Address
Please Select
1851 Virginia Ave
Harrisonburg VA 22802
Ordering Provider City
Please Select
Harrisonburg
Ordering Provider Zip Code
Please Select
22802
Is patient pregnant?
Please Select
Yes
No
Unknown
Patient Race
*
Please Select
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Pacific Islander
White
Other
Unknown
Specify other race
Patient Ethnicity
*
Please Select
Hispanic or Latino
Not Hispanic or Latino
Unknown
Test Name
Please Select
Mesa Biotech Accula SARS-CoV-2
Specimen Type
Please Select
Nasal Swab
Specimen Collected and Tested by
Symptoms (symptoms may occur 2-14 days after exposure to the virus)
If symptomatic when did they first occur?
-
Month
-
Day
Year
Date
Is this your first Covid test?
Yes
No
Are you employed in healthcare?
Yes
No
Were you hospitalized?
Yes
No
Were you in the ICU?
Yes
No
Were you a resident in a congregate care setting? (Nursing Home, residential care for people with intellectual and developmental disabilities, psychiatric treatment facilities, group homes, board and care homes, homeless shelter, foster care, or other setting?)
Yes
No
Physician Information (Optional)
PCR Covid Test Fee $169.00
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PCR Covid Test Fee
PCR Covid test fee. This test will not be billed to insurance by Medicap Pharmacy. You can ask for a receipt after the test is performed to bill insurance if you choose. Coverage is not guaranteed. You can pay with cash or check if you don't want to use a credit card. Uncheck this box if you do not want to pay with a credit card.
$
169.00
Credit Card
First Name
Last Name
Credit Card Number
Security Code
Expiration Date
Postal Code
I FULLY UNDERSTAND THAT THIS TEST WILL NOT BE BILLED TO ANY INSURANCE BY MEDICAP PHARMACY. I accept the fee of $169.00 and it is up to my insurance to determine my coverage. In consideration of my participation in this test, I hereby agree to assume all risks. I also understand that results are not designed to replace the care or advice of a medical provider. I understand that if I receive abnormal laboratory test results I should promptly consult with a physician. To agree to participate in this test please sign this form.
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