Rapid Covid/Flu Antigen Test

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Please read the following statement in it's entirety: *Tests are $99 and non-refundable.* These are Rapid Covid/Flu A&B Antigen Test. Please verify with your end user if they will accept this test as clearance, if this test is intended for such purpose: work, travel, nursing home, hospital, etc. By signing your name, you agree to our terms that PHARMACY TOWN LLC will not be held responsible for any representations.* This field is required.
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Appointment
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Date and Time of Test Confirmation* This field is required.You must have an appointment TIME slot booked on the previous page. Please enter it here
Date
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Day
Year
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Minutes
PM
AM
PM
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Patient Name* This field is required.
First Name
Middle Initial
Last Name
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Gender* This field is required.
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Date of Birth* This field is required.MM-DD-YYYY
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Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
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Australia
Austria
Azerbaijan
The Bahamas
Bahrain
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Belarus
Belgium
Belize
Benin
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Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
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Brunei
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Burkina Faso
Burundi
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Canada
Cape Verde
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Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
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Cook Islands
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Cote d'Ivoire
Croatia
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Democratic Republic of the Congo
Denmark
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Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
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Italy
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Montserrat
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Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
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Turkish Republic of Northern Cyprus
Northern Mariana
Norway
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Poland
Portugal
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Qatar
Republic of the Congo
Romania
Russia
Rwanda
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Saint Helena
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Saint Lucia
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Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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Cell Phone* This field is required.
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Email* This field is required.Needed if you need the results emailed to you
example@example.com
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Race** This field is required.Required By CDC
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Ethnicity** This field is required.Required By CDC
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Insured's Name
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COVID 19 (SARS CoV 2 Assay) via Nasal Swab* This field is required.
RAPID ANTIGEN COVID 19 (SARS CoV 2 Assay) via Nasal Swab
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ICD-10 Code* This field is required.PLEASE STAY IN YOUR CAR AND PULL UP TO THE FRONT OF THE STORE IF YOU ARE SYPTOMATIC OR HAVE BEEN EXPOSED TO SOMEONE WITH COVID. DO NOT COME INSIDE.
Z20.828 Contact with and suspected exposure to other viral communicable disease (DO NOT COME INSIDE, STAY IN YOUR CAR)
Z11.59 Asymptomatic, no known exposure, results unknown or negative
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Payment* This field is required.
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ORDER SUMMARY
Total costUSD
COVID-19-FLU A/FLU BThis is NON-REFUNDABLE. If you cancel or no-show, you will not receive a refund.
$99.00+Edit
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Total cost $0.00
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Invoice ID
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Results under FDA approved under EUA category, BD VERITOR TEST for Influenza A+b
NEGATIVE
POSITIVE
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Results under FDA approved under EUA category, BD VERITOR TEST for detection of SARS-CoV-2
NEGATIVE
POSITIVE
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