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 Name Last Name
Address *

Street Address

Street Address Line 2

City State / Province

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

Male Female Other
Race *

White American Indian or Alaska Native Asian Black or African American Native Hawaiian or other Pacific Islander Unknown
Ethnicity *

Hispanic or Latino Not Hispanic or Latino Unknown
Drivers License/Government Issued ID or Any Proof of Address (Please Click upload after selecting the file) *

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

Fever or chills Cough Shortness of breath or difficulty breathing Fatigue Muscle or body aches Headache Loss of taste or smell Sore throat Congestion or runny nose Nausea or vomiting Diarrhea Persistent pain or pressure in the chest None 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.pdf I have traveled to a high-risk location I 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

Z20.828 Z03.818 Z11.59
Collection Billing Code

99074
COVID-19 Rapid Antigen Test Result

Positive Negative
Should be Empty: