NEW Pine Plains Pharmacy COVID-19 Testing Form

Pine Plains Pharmacy COVID-19 Testing Form

2965 Church Street, Pine Plains, NY 12567 518-398-5588 Pineplainsrx2@gmail.com

Charges for Service *

Abbott BinaxNOW Ag Rapid Test. 30 Minute Results This is an antigen test for an active COVID-19 infection that detects specific proteins on the surface of the virus. Both the collection (via nasal swab) and the test are performed at Pine Plains Pharmacy and the patient will have the results that same day.

$ 95.00

Same day Results COVID-19 Rapid RT-PCR Test (Molecular/NAAT) This is a RT(Real-Time) PCR test for an active COVID-19 infection. Both the collection (via direct nasal, nasopharyngeal, or throat swab) and the test are performed at Pine Plains Pharmacy and the patient will have the results that same day. (Results in 1-2 hours used for travel)

$ 250.00

Enter coupon

Total

$ 0.00

Credit Card

Basic Demographic Information
Name *

First Name Middle Name Last Name Suffix
Gender *
Date of Birth *

Month (MM) Day (DD) Year (YYYY)
Are you currently pregnant or have been pregnant in the past 4 weeks? *
Race (Check all that apply)

Black or African American White Asian Native Hawaiian or Other Pacific Islander American Indian or Alaska Native Other
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
County
Email *
example@example.com
Home/Cell Phone *
Please enter a valid phone number.
Work Phone
Please enter a valid phone number.
Primary Care Provider Name:
Primary Care Provider Phone
Please enter a valid phone number.
Work and School Information
I am . . . (check all that apply)

Employed Attending School Other
Employer Name
Employer Phone
Please enter a valid phone number.
Employer Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
School Name
School District
School Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Have you attended school in the past 7 days?

Yes No
Screening Questions
Have you experienced any of the following symptoms?

Fever or Chills Fatigue, Muscle Aches, or Body Aches Headache Cough, Shortness of breath or Difficulty Breathing Recent Loss of taste or smell Nausea, Vomiting or Diarrhea Sore Throat or Congestion
Date Symptoms Started

Month Day Year
In the Past 14 Days Have You (check all that apply)

Had contact with anyone that has had COVID-19 or COVID-19 like symptoms Been on a commerical flight or traveled outside the United States Been in close proximity to someone who has been on a commercial flight or traveled outside the United States.
Reason For Testing *

Travel, or to end Travel Related Quarantine I have symptoms and/or was exposed to someone who has COVID-19 I have no symptoms but was exposed to someone that has/had COVID-19 Other
Have you previously been tested for COVID-19?

Yes No
What was the Result of your previous COVID-19 Test?
Date of Previous COVID-19 Test

Month Day Year
Testing Safety
We will be performing CURBSIDE COVID-19 TESTING ONLY - PLEASE DO NOT ENTER THE PHARMACY FOR TESTING . Once you arrive, call the pharmacy and WE WILL COME OUT TO YOUR CAR.
I have read the above paragraph and understand the above paragraph *
Initial to indicate agreement.
Appointment (will be scheduled only after form is completed) *
Appointment Details
I authorize the collection and testing for COVID-19 through an oropharyngeal (throat), nasal, and/or nasopharyngeal swab, as ordered by an authorized medical provider/public health official.

By voluntarily agreeing to this testing, I understand that my test results will be disclosed to the county, state, or any other government entity as may be required and/or permitted by law, and that my test results will be reported to the operator of my facility.

I understand that Pine Plains Pharmacy employees, volunteers, and contractors, who are collecting specimens and providing test results. This specimen collection and testing does not replace treatment by my medical provider. I assume complete and full responsibility to take appropriate action with regard to my test results. I agree I will seek medical advice, care, and treatment from my medical provider if I have questions or concerns, or if my condition worsens.
I agree the above terms and conditions *

Yes No
Your signature below indicates your consent for COVID-19 Testing at Pine Plains Pharmacy *

Clear
Please type out your name, if you are not the patient please indicate your relationship *
Name and Relationship (If not the patient)
If you are booking this test for travel, it is your resposibility to confirm the test that you are taking here is acceptable by your Airlines.

Refund Policy
There are no refunds for COVID testing once you confirm payment. You can reschedule to another date and time or we can offer you a free test voucher, should you miss your scheduled testing appointment.
Appointment time
PCR Agreement.

PCR TESTING IS NOT AVAILABLE ON SATURDAY.

IF YOU REQUIRE A PCR TEST IT MUST BE MADE FOR MONDAY-FRIDAY

The number to contact the Pharmacy is: +1 (518) 398-5588

Note: The standard 24-48 hour window still applies to all PCR tests.
I agree to the below information about my PCR test:

I have not scheduled my PCR test for Saturday.
I have read and agree to the all the terms above * *

Clear
Collection Date

Month Day Year
Date
Hour Minutes AM/PM Option
Result Date

Month Day Year
Date
Hour Minutes AM/PM Option
Ascension Number
Test Result

Positive Negative Rescheduled Cancelled No Show Other
Patient is:

Curbside Symptomatic Confirmed Exposure
Route of swab
Payment:

Credit Card Cash Paid Customer Invoiced
Confirm:

DOB PCP
Amount Charged
Test Type
Testing Provider
Pine Plans Pharmacy 
2965 Church St, 
Pine Plains, NY 12567 
Phone: 518-398-5588
Should be Empty:

Pine Plains Pharmacy COVID-19 Testing Form

Credit Card

Basic Demographic Information

Work and School Information

Screening Questions

Testing Safety

Appointment Details