Wellness Rx LLC Pharmacy
Rapid COVID Test Appointment Form for HTC
You MUST be a student, faculty member, or staff member of Hunter Tannersville Central School to get this test.
Parents and siblings who are not students are NOT eligible for this testing.
This form is to schedule a COVID-19 Rapid test: Abbott ID PCR or Abbott BiaNEXT NOW
COVID-19 testing takes place at Wellness Rx, 5980 Main St. Tannersville, on the FRONT porch in the small room on the left side. Please call 518-589-9500 to let us know you've arrived for your test. We will give you further instructions. PLEASE DO NOT COME INSIDE THE STORE! Your results will be available in 15-20 minutes. The pharmacist will ask you to either wait in the testing room or in your car for your paper test results, we can also email you the results if needed.
Appointment Scheduler
*
Are you:
*
A student at HTC
A faculty member at HTC
A staff member at HTC
Name of person getting tested
*
First Name and Middle Initial
Last Name
Parent or Guardian (if minor getting tested:)
First Name
Last Name
Patient Age:
*
Patient Birthdate
*
-
Month
-
Day
Year
Date
Primary Address
*
Street Address
(PO Box or apartment number)
City
State / Province
Postal / Zip Code
County (where you primarily reside)
*
(example: Greene, Columbia, Ulster)
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Gender
*
Please Select
Male
Female
Other
Race
*
Please select
Native American or Alaskan
African American or Black
Asian
Native Hawaiian or Pacific Islander
White
Other or Multiracial
Declined
Ethnicity
*
Please Select
Declined
Hispanic Origin
Non-Hispanic Origin
Unknown
Please select
Pregnant or Postpartum
*
Please Select
No
Yes
Unknown
N/A
Reason for testing
*
Please Select
Travel, or to end travel quarantine
I have symptoms, and/or I was exposed to someone with COVID-19
I have NO symptoms, but I was exposed to someone with COVID-19
Other
Was the patient at school in the past 7 days?
*
yes
no
Are you actively displaying symptoms of COVID-19?
*
Please Select
Yes
No
Symptoms onset date if applicable
-
Month
-
Day
Year
Date
Should you schedule an appointment and be unable to make your appointment time please call 518-589-9500 to let us know.
Thank you!
COVID-19 Testing Consent Form
A sample will be collected from you or your child by nasal swab. A trained healthcare professional from Wellness Rx will be collecting the Nasal Swab (front/sides of nose).
Please carefully read the following notice and sign the authorization to test for COVID-19.
I understand that the COVID-19 testing will be conducted with an Abbott ID rapid molecular PCR test, or other acceptable test as ordered by an authorized medical provider or a public health official. I understand that I am not creating a patient relationship with the ordering physician by participating in this testing. I understand the entity performing the test 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 and my medical care. I agree I will seek medical advice, care, and treatment from my medical provider or other health care entity if I have questions or concerns, if I develop symptoms of COVID-19, or if my condition worsens. I understand it is my responsibility to inform my health care provider of a positive test result, and that a copy will not be sent to my health care provider for me. I understand that my antigen test result will be available in 15-30 minutes. I understand and acknowledge that a positive test result is an indication that I need to self-isolate to avoid infecting others until I obtain a negative PCR test result. I have been informed of the test purpose, procedures, and potential risks and benefits. I will have the opportunity to ask questions before proceeding with a COVID-19 diagnostic test at the testing site. I understand that if I do not wish to continue with the COVID-19 diagnostic test, I may decline to take the test. If I decline to take the test, I may be unable to participate in certain activities, such as athletic practice or competition. I understand that I may withdraw my consent to participate in testing at any time.
AUTHORIZATION/CONSENT TO TEST FOR COVID-19
*
I agree to undergo COVID-19 testing
I agree to authorize my child to undergo COVID-19 testing.
Signature for 18 and older or Parent/Guardian
*
Clear
Submit
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