Informed Consent for COVID-19 Testing- Meyer Pharmacy

COVID-19 Testing

Meyer Pharmacy is currently offering two different types of rapid COVID-19 tests. Both of these tests are performed by collection of a nasal swab sample. We do not bill insurance for these tests, but patient may submit costs to insurance for potential reimbursement.
Please choose one of the COVID-19 Tests available: *

BD Veritor COVID-19 Test (Antigen Test)-Results will be provided within 1 hour. $89 Accula COVID-19 Test (RT-PCR Test)- Results will be provided within 2 hours. $179
***PLEASE NOTE***

If you are needing a COVID test for travel puproses, please be sure to review the requirements for travel based on your destination (what type of test is needed).
Are you currently experiencing any symptoms of COVID-19 such as: fever, chills, cough, shortness of breath, difficulty breathing, fatigue, body aches, headache, loss of taste or smell, sore throat, nausea, vomiting, or diarrhea? *

Yes No
Fact Sheet for Patients

Please click on the link below to read the Fact Sheet for the testing system being used to analyze your sample and complete the acknowledgement statement after reading the document. A printed copy of this information will be available at the pharmacy upon request.
BD Veritor System for Rapid Detection of SARS-CoV-2 Fact Sheet for Patients
Accula SARS-CoV-2 Test Fact Sheet for Patients
Please check below to acknowledge you have read fact sheet for the test to be provided. *

Yes, I have read the information provided above.

COVID Testing Appointment

Please keep your appointment or call the pharmacy if you need to cancel or change it. To maintain social distancing guidelines, please wear a mask, remain in your vehicle, and call the pharmacy when you arrive for your appointment. A staff member will come to your vehicle to collect a nasal swab sample.
Please select an available appointment (date and time) for your COVID-19 test: . *
***PLEASE NOTE***

You will be notified of your results by phone. Written documentation of your results can be provided if needed.

Patient Information
Patient Full Legal Name (If test is for travel purposes, please enter name exactly as it appears on your ID) *

First Name Middle Name Last Name
Date of Birth *

Month Day Year
Date
Age *
Gender *

Female Male
Patient Phone Number *
***Cell Phone number preferred***
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Race/Ethnicity: *

Caucasian African American Hispanic Asian American Indian Pacific Islander Other
Email
Please enter your email address here if you would like to receive an Email confirmation of your appointment.
Primary Care Provider (PCP) Name

First Name Last Name
Current date

Month Day Year
Date

	Yes	No
Have you been given a COVID-19 vaccine in the past 9 months?
Do you have any medical conditions?
If applicable, are you currently pregnant?
Are you employed in healthcare?
Do you live in a congregate care setting such as a nursing home or group home facility?
Are you experiencing symptoms of COVID-19 such as: fever, chills, cough, shortness of breath, difficulty breathing, fatigue, body aches, headache, loss of taste or smell, sore throat, nausea, vomiting, or diarrhea?

COVID-19 Testing