Payment Collection 

Once you submit this form, a staff member will contact you before your selected appointment time to finalize your appointment. At this time, they will also collect the nonrefundable fee of $130. This fee will not be billed to insurance.

Appointment Information

All appointment times are not final or confirmed until the pharmacy has contacted you and received payment.

At the time of your appointment, please stay in your car and give us a call to let us know you've arrived. A staff member will come out to perform the test from the comfort and safety of your vehicle.  

Our Address
2409 Box Butte Ave.
Alliance NE, 69301

Consent for Testing

 If you have any questions about the following statements please contact us at (308) 629-1045

You will receive a paper copy of this form at the time of your appointment.

To proceed with receiving the test, I confirm and understand the following.

I understand that the novel Coronavirus (COVID-19) has been declared a global pandemic by the World Health Organization (WHO). I further understand that COVID-19 is extremely contagious and may be contracted from various sources. I understand COVID-19 has a long incubation period during which carriers of the virus may not show symptoms and still be contagious. 

I understand that I am the decision maker for my health care. To the best of their ability, Alliance Community Pharmacy will provide me with information to assist me in making informed choices. This process is often referred to as "informed consent" and involves my understanding and agreement regarding recommended care, and the benefits and risks associated with testing during the pandemic. Given the current limitations of COVID-19 virus testing, I understand determining who is infected with COVID-19 is exceptionally difficult.

I understand that preventative measures and intensified sanitation protocols intended to reduce the spread of COVID-19 have been implemented. However, because this work involves close physical proximity, there may be an elevated risk of disease transmission, including COVID-19. I hereby give my express permission to you and the staff at Alliance Community Pharmacy to proceed with rapid antigen testing.

I have been offered a copy of this consent form.

I KNOWINGLY AND WILLINGLY CONSENT TO THE TESTING WITH THE FULL UNDERSTANDING AND DISCLOSURE OF THE RISKS ASSOCIATED WITH TESTING DURING THE COVID-19 PANDEMIC. I CONFIRM ALL OF MY QUESTIONS WERE ANSWERED TO MY SATISFACTION. I HAVE READ, OR HAVE HAD READ TO ME, THE ABOVE COVID-19 RISK INFORMED CONSENT TO TEST. I HAVE ALSO HAD AN OPPORTUNITY TO ASK QUESTIONS ABOUT ITS CONTENT, AND BY SIGNING BELOW, I AGREE WITH THE CURRENT OR FUTURE RECOMMENDATION TO RECEIVE TESTING AS IS DEEMED APPROPRIATE FOR MY CIRCUMSTANCE.

If you are under the age of 18 please have a parent or guardian approve these terms on the next slide. A parent or guardian must be present at the time of your appointment.