COVID TESTING QUESTIONNAIRE

COVID TESTING
What type of COVID Test are you interested in?*

Abbott ID-NOW(NAAT) COVID-19 Molecular PCR Test $150 (results within 1-2 hours, "Gold Standard")Rapid Antigen Test $75 (results within 15-30 minutes)
Desired Testing Date*

MonthDayYear
Date
****Please fill out this form no sooner than 24 hours prior to your expected testing date and time****

****Forms submitted prior to this will need to be completed again before testing
Name*

First NameMiddle NameLast Name
Date of Birth*

MonthDayYear
Date
Age*
Gender*

MaleFemale
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Primary Care Provider

First NameLast Name
Ethnicity*

Please answer the following questions*

	Yes	No	???
Do you have a fever or illness today
Have you or a household contact been diagnosed with COVID-19 in the last 14 days?
Have you been in close physical contact (6 feet or closer for a cumulative total of 15 minutes) with anyone whoa has symptoms consistent with COVID-19 in the past 14 days?
Are you isolating or quarantining because you may have been exposed to anyone with COVID-19?
Are you worried that you may be sick with COVID-19?
Are you Currently waiting ont the results of a COVID-19 Test?

Have you received a COVID-19 Vaccine?*
Have you experienced any of the following in the past 14 days?*

Fever > 100.4 FSore ThroatRunny NoseStuffy NoseMuscle AchesShortness of BreathDifficulty BreathingNew loss of taste or smellCoughHeadacheFatigueVomitingDiarrheaChillsNauseaNo Symptoms
Do you have any of the following chronic conditions or or long-term health problems?*

AnemiaAsthmaDiabetesHeart DiseaseKidney DiseaseLiver DiseaseLung DiseaseObesityCancerCOPDSmokerImmunocompromisedSickle Cell DiseaseNone
How long have you had symptoms?
Consent to Testing
I hereby authorize Gary & Leo’s Pharmacy to perform a COVID-19 Test. I authorize the pharmacy to maintain a copy of this signed form. 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 that my results will be submitted to the Montana Department of Health, as required by law. By signing below, I signify that I agree to allow those pharmacy employees affiliated with the pharmacy named above to administer the COVID-19 test for a fee. I understand that my insurance might not reimburse the fee for the test and hold the pharmacy and pharmacist harmless for any fees not reimbursed. Antigen tests look for viral proteins, which are highly specific, meaning that if you test positive, you are very likely infected. However, there is a higher chance of false negative with antigen tests, which means that a negative result cannot definitively rule out an active infection. If you have a negative result on an antigen test but have a recent exposure to COVID, or are displaying many of the symptoms, you may wish to take a PCR test to confirm your result. A PCR test looks for the presence of the virus' genetic material. PCR tests are highly accurate. The antigen test is most accurate if you are symptomatic and within the first five days of symptoms. If you are testing to meet a travel requirement, it is your responsibility to determine if you are required to take a PCR test or an antigen test.

Please avoid contact with others and go straight home immediately after your test. You will be contacted via phone with your results.
I understand if my results are positive I should follow-up with my primary care provider*

I agree
Signature*

Clear
Date*

MonthDayYear
Date
TEST GIVEN: MOLECULAR OR ANTIGEN

BRAND:______________________ LOT:______________ EXP:______________

RESULTS: POSITIVE OR NEGATIVE

EMPLOYEE:____________________________________________

DATE:_______________________________________________
Should be Empty:

COVID TESTING

****Please fill out this form no sooner than 24 hours prior to your expected testing date and time****

Consent to Testing

Please fill out this form no sooner than 24 hours prior to your expected testing date and time