COVID-19 Rapid Antigen Test - Medical Mall Pharmacy

COVID-19 Rapid Antigen Test

Result in 15-20 Mins $50 (Pay at the pharmacy) We do not have way to bill the insurance for a Rapid test
Select a time slot for your COVID-19 Testing Appointment*
Patient Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

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

MaleFemaleOther
Race*

WhiteAmerican Indian or Alaska NativeAsianBlack or African AmericanNative Hawaiian or other Pacific IslanderUnknown
Ethnicity*

Hispanic or LatinoNot Hispanic or LatinoUnknown
Drivers License/Government Issued ID or Any Proof of Address (Please Click upload after selecting the file) *

Cancelof
Have you experienced any of below symptoms in last 5 Days?*

Fever or chillsCoughShortness of breath or difficulty breathingFatigueMuscle or body achesHeadacheLoss of taste or smellSore throatCongestion or runny noseNausea or vomitingDiarrheaPersistent pain or pressure in the chestNone of the above
Please check all that applies below*

I have had close contact (within 6 feet of an infected person for at least 15 minutes in a 24 hour period)with someone with confirmed COVID-19). It is recommended to wait at least 5 to 7 days after exposure for testing. Why you Can't Test Out of COVID-19 Quarantine* https://www.nj.gov/health/cd/documents/topics/NCOV/COVID-Cannot-Test-Out-of-Quarantine.pdfI have traveled to a high-risk locationI have been asked or referred to get testing by a healthcare provider or local or state health department.I agree to terms & conditions of Medical Mall Pharmacy. I acknowledge the Medical Mall Pharmacy Notice of Privacy Practices, testing practices & financial disclosures. *
By Signing and clicking submit below. You hereby confirm that the information you have given above is true, and that you will comply with the terms and conditions outlined above. You also agree that date of submission will be the date of your consent.
Signature*

Clear
Diagnosis Code

Z20.828Z20.822Z11.59
Collection Billing Code

99074
COVID-19 Rapid Antigen Test Result

PositiveNegative
Should be Empty: