Simple Report COVID-19 BinaxNOW Test Appointment & Consent Form

Please pay close attention to the day and time of your appointment. You will be charged the $50 during your appointment. Thank you for helping us keep our patients and staff safe and healthy.

Select a 10-minute time slot for your COVID-19 Testing Appointment*

Name*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Date of Birth*

Date

Mobile Phone Number*

Please enter a valid phone number.

Phone type*

MobileLandline

Would you like to receive your results via text message?

YesNo

Email

example@example.com

Race*

Are you Hispanic or Latino?*

YesNoPrefer not to answer

Email

example@example.com

Sex assigned at birth *This is usually the gender that is written on your original birth certificate.*

FemaleMaleOther

If female, are you pregnant?

YesNo

Are you experiencing symptoms?*

YesNo

Date of onset of symptoms

Date

List your symptoms (If applicable)

You MUST fill out and submit the SimpleLink form below, then scroll down to sign and hit Submit for a SECOND time to schedule your appointment.

Keep scrolling down to sign and hit

SUBMIT to schedule appointment.

IMPORTANT INFORMATION

Please come through our Drive-Thru at the time of your scheduled test.

WE DO NOT BILL INSURANCE FOR THESE TESTS, BUT YOU MAY SUBMIT TO YOUR INSURANCE TO ATTEMPT REIMBURSEMENT.

COVID TESTING IS MOST ACCURATE WHEN PERFORMED AT LEAST 8 DAYS AFTER A POSSIBLE EXPOSURE. TESTING EARLIER THAN 8 DAYS COULD RESULT IN A FALSE NEGATIVE.

IF BEING USED FOR TRAVEL IT IS THE PATIENT'S RESPONSIBLITY TO CHECK WITH THEIR AIRLINE OR DESTINATION TO MAKE SURE THE TEST WILL BE ACCEPTED.

SERVICE:

COVID - Rapid Antigent Test: $50

This test uses a self-administered nasal swab that is inserted into each nostril less than one inch. You will swirl the swab around the inside of each nostril 5 times and we will coach you on proper technique. This is a very comfortable and easy swab to perform. We analyze the results onsite and report back to you in about 30 minutes.

This is not a PCR test and may NOT be used to shorten quarantine time for school or daycare children who have no symptoms. For travel, please verify the type of test you need (this test is antigen, not PCR). For ages 3 and up only. Younger children will need to have a parent/guardian perform the swab on them.

By submitting the form below you acknoledge that you are the patient listed on this form or the legal parent/guardian of the patient (if less than 18) and you agree to the following:

I hereby authorize staff at Duvall Family Drugs to perform a Covid-19 Rapid Antigen Test. I authorize the pharmacists to maintain a copy of this signed form and submit all information to local health departments as required. 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.

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 that if I test positive, I am very likely infected. False negatives are possible, either because the test does not detect viral particles present, or because it is too early or late in an infection. The test you are receiving today is an antigen test.

I understand that if my result is positive, I should follow up with my primary care doctor and local health department. I understand that this testing site is not acting as my medical provider. Testing does not replace treatment by my medical provider. I assume complete and full responsibility to take appropriate action with regards to my test results.

By signing this form I attest that I voluntarily agree to testing for COVID-19. I understand the test purpose procedures, possible benefits and risks. I understand that I may ask questions regarding the test at any time.

Signature

COVID-19 Rapid Antigen Test Appointment & Consent Form