• Downtown Pharmacy COVID-19 Testing Consent and Intake Form

  • COVID-19 TESTING - PATIENT INTAKE FORM

    Effective August 1, 2020 section 18115 of the Coronavirus Aid, Relief, and Economic Security (CARES) Act (Public Law 116-136) requires all clinical laboratories to report demographic data on each individual tested for COVID-19. Failure to report COVID-19 test results along with demographic data may result in revocation of a laboratory's clinical lab permit. We appreciate your compliance with this new regulation.

  • Testing Times are as follows (subject to change):

    Monday through Friday 

    10AM to 4PM

    Saturday and Sunday

    11AM to 4PM

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  • In the last 14 Days:

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  • Please carefully read and sign the following Informed Consent:

    a. I authorize this COVID-19 testing unit to conduct collection and testing for COVID-19 through a nasal or nasopharyngeal swab, as ordered by an authorized medical provider or public health official.

    b. I authorize my test results to be disclosed to the county, state, or to any other governmental entity as may be required by law.

    c. I acknowledge that a positive test result is an indication that I must self-isolate and/or wear a mask or face covering as directed in an effort to avoid infecting others.

    d. I understand the testing unit is not acting as my medical provider, this testing does not replace treatment by my medical provider, and I assume complete and full responsibility to take appropriate action with regards to my test results. In the event that the test is positive, I agree I will seek medical advice, care and treatment from my medical provider if I have questions or concerns, or if my condition worsens.

    e. I understand that, as with any medical test, there is the potential for a false positive or false negative COVID-19 test result. I agree to pay the fees for the above chosen test, and understand that said fees are NOT REFUNDABLE

    I, the undersigned, certify that my responses on this form are true and correct.  I have been informed about the test purpose, procedures, possible benefits and risks, and I have received a copy of this Informed Consent. I have been given the opportunity to ask questions before I sign, and I have been told that I can ask additional questions at any time. I voluntarily agree to this testing for COVID-19.

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