Covid-19 Rapid Antigen Test Form-$39

Patient Name *

Date of Birth*

Date

Patient Street Address*

City*

State*

Zip Code*

Telephone*

Email*

example@example.com

I hereby authorize the pharmacist from Stine’s Apothecary to perform a Covid-19 Rapid Antigen Test. I authorize the pharmacists to maintain a copy of this signed form. I indemnify the organizing body and all persons connected with them from any and all claims that may result from my voluntary participation in the tests.

By signing below, I signify that I agree to allow those pharmacists affiliated with the pharmacy name above to administer the COVID-19 rapid test for a fee of $39.00.

I understand the test that I am receiving is a rapid diagnostic test using antigens. Antigen tests look for viral proteins, which are highly specific, meaning if you test positive, you are likely infected. However, there is a higher chance of false negatives with antigen tests, which means that a negative result cannot definitively rule out an active infection. If you have a negative result on an antigen test but have a recent exposure to Covid, or are displaying any of the symptoms, you may wish to take a PCR test to confirm your result. A PCR test looks for the presence of the virus’s genetic material. PCR tests are highly accurate but can take days to a week to get the results. The antigen test that you are receiving today is most accurate if you are symptomatic and within the first five days of symptoms.

If you are testing to meet a travel requirement, it is your responsibility to determine if you are required to take a PCR test or an antigen test. The test you are receiving today is an antigen test.*

I understand if my results are positive I should follow-up with my primary provider.

Patient Signature (Parent/Guardian Signature & Consent if patient is under 18 years of age)*

Clear

Date*

Date

Primary Care Doctor*

Primary Care Doctor Telephone*

To be completed by Pharmacist: Test Result

PositiveNegative

Pharmacist Signature*

Clear

Date

The pharmacy and its pharmacists comply with the Health Insurance Portability and Accountability Act of 1996 (“HIPPA”) with regard to the Protected Health Information you provide on this form. The pharmacy and its pharmacists take your health informative privacy very seriously, and shall use, disclose, and maintain your Protected Health Information only as permitted by HIPAA.