By signing below, I verify that I have read or had explained to me the information about the test I am receiving. I have had a chance to ask questions which were answered to my satisfaction. I understand the risks and request the respective test to be given to me or the above named person for whom I am authorized to make this request. I have been made aware and provided access to Martin-Tipton Pharmacy's Notice of Privacy Practices.
I give permission to Martin-Tipton Pharmacy to administer the test.
I understand that: I must personally be responsible for payment of services as provided. Martin-Tipton Pharmacy will send my results via email address I provide. I can opt out of emailing results but will have to wait on results or return to get them.
Notice: There is still a threat of COVID-19 and we are doing everything possible to make sure our customers and staff stay healthy. Please note, if you are over the age of 65, you are coming into our facility on your own accord. Sign and date below that you acknowledge and will abide by all standards.