You can always press Enter⏎ to continue
Welcome

Welcome

Please fill out this form. Note at this time Vashon Pharmacy cannot bill medical insurance for these services. Payment will be collected at the end of this signup and no reimbursement will be made from Vashon Pharmacy. We are working hard to be able to bill medical insurance and are hopeful that by end of year 2022 we will have that capability. 
22Questions
  • 1

     

     

    This form is to sign up for a fee for service program offered by Vashon Pharmacy. These services are meant to close gaps in care on Vashon Island. 

    The cost of these services is outlined on the following slide and a secure payment portal using Square will collect payment prior to submission if necessary. Click next at the bottom of the page to proceed and provide the necessary information needed. 

     

    Click next/arrow below to proceed

     

    Press
    Enter
  • 2

    Types of tests offered by Vashon Pharmacy and the associated out-of-pocket cost of each. 

     

     

    Rapid-Moleculer - COVID  19 (Travel/Medical/Event) - $65

    Rapid Strep - $45

     

     

    Click next/arrow below to proceed

    Press
    Enter
  • 3

    Who can administer their tests...

     

    Children 5 and under will have their test administered by a practitioner at the test site. 

    Children age 6-18 will need to have their swab observed by an adult or practitioner. 

    Adults age 18 and up may administer their own swab if comfortable and be asked to return the sample.

    Click next/arrow below to proceed

    Press
    Enter
  • 4
    Press
    Enter
  • 5
    Press
    Enter
  • 6
    Press
    Enter
  • 7
    Please type using MM-DD-YYYY format
    Press
    Enter
  • 8
    Press
    Enter
  • 9
    Press
    Enter
  • 10
    Please Select
    • Please Select
    • United States
    • Afghanistan
    • Albania
    • Algeria
    • American Samoa
    • Andorra
    • Angola
    • Anguilla
    • Antigua and Barbuda
    • Argentina
    • Armenia
    • Aruba
    • Australia
    • Austria
    • Azerbaijan
    • The Bahamas
    • Bahrain
    • Bangladesh
    • Barbados
    • Belarus
    • Belgium
    • Belize
    • Benin
    • Bermuda
    • Bhutan
    • Bolivia
    • Bosnia and Herzegovina
    • Botswana
    • Brazil
    • Brunei
    • Bulgaria
    • Burkina Faso
    • Burundi
    • Cambodia
    • Cameroon
    • Canada
    • Cape Verde
    • Cayman Islands
    • Central African Republic
    • Chad
    • Chile
    • China
    • Christmas Island
    • Cocos (Keeling) Islands
    • Colombia
    • Comoros
    • Congo
    • Cook Islands
    • Costa Rica
    • Cote d'Ivoire
    • Croatia
    • Cuba
    • Curaçao
    • Cyprus
    • Czech Republic
    • Democratic Republic of the Congo
    • Denmark
    • Djibouti
    • Dominica
    • Dominican Republic
    • Ecuador
    • Egypt
    • El Salvador
    • Equatorial Guinea
    • Eritrea
    • Estonia
    • Ethiopia
    • Falkland Islands
    • Faroe Islands
    • Fiji
    • Finland
    • France
    • French Polynesia
    • Gabon
    • The Gambia
    • Georgia
    • Germany
    • Ghana
    • Gibraltar
    • Greece
    • Greenland
    • Grenada
    • Guadeloupe
    • Guam
    • Guatemala
    • Guernsey
    • Guinea
    • Guinea-Bissau
    • Guyana
    • Haiti
    • Honduras
    • Hong Kong
    • Hungary
    • Iceland
    • India
    • Indonesia
    • Iran
    • Iraq
    • Ireland
    • Israel
    • Italy
    • Jamaica
    • Japan
    • Jersey
    • Jordan
    • Kazakhstan
    • Kenya
    • Kiribati
    • North Korea
    • South Korea
    • Kosovo
    • Kuwait
    • Kyrgyzstan
    • Laos
    • Latvia
    • Lebanon
    • Lesotho
    • Liberia
    • Libya
    • Liechtenstein
    • Lithuania
    • Luxembourg
    • Macau
    • Macedonia
    • Madagascar
    • Malawi
    • Malaysia
    • Maldives
    • Mali
    • Malta
    • Marshall Islands
    • Martinique
    • Mauritania
    • Mauritius
    • Mayotte
    • Mexico
    • Micronesia
    • Moldova
    • Monaco
    • Mongolia
    • Montenegro
    • Montserrat
    • Morocco
    • Mozambique
    • Myanmar
    • Nagorno-Karabakh
    • Namibia
    • Nauru
    • Nepal
    • Netherlands
    • Netherlands Antilles
    • New Caledonia
    • New Zealand
    • Nicaragua
    • Niger
    • Nigeria
    • Niue
    • Norfolk Island
    • Turkish Republic of Northern Cyprus
    • Northern Mariana
    • Norway
    • Oman
    • Pakistan
    • Palau
    • Palestine
    • Panama
    • Papua New Guinea
    • Paraguay
    • Peru
    • Philippines
    • Pitcairn Islands
    • Poland
    • Portugal
    • Puerto Rico
    • Qatar
    • Republic of the Congo
    • Romania
    • Russia
    • Rwanda
    • Saint Barthelemy
    • Saint Helena
    • Saint Kitts and Nevis
    • Saint Lucia
    • Saint Martin
    • Saint Pierre and Miquelon
    • Saint Vincent and the Grenadines
    • Samoa
    • San Marino
    • Sao Tome and Principe
    • Saudi Arabia
    • Senegal
    • Serbia
    • Seychelles
    • Sierra Leone
    • Singapore
    • Slovakia
    • Slovenia
    • Solomon Islands
    • Somalia
    • Somaliland
    • South Africa
    • South Ossetia
    • South Sudan
    • Spain
    • Sri Lanka
    • Sudan
    • Suriname
    • Svalbard
    • eSwatini
    • Sweden
    • Switzerland
    • Syria
    • Taiwan
    • Tajikistan
    • Tanzania
    • Thailand
    • Timor-Leste
    • Togo
    • Tokelau
    • Tonga
    • Transnistria Pridnestrovie
    • Trinidad and Tobago
    • Tristan da Cunha
    • Tunisia
    • Turkey
    • Turkmenistan
    • Turks and Caicos Islands
    • Tuvalu
    • Uganda
    • Ukraine
    • United Arab Emirates
    • United Kingdom
    • Uruguay
    • Uzbekistan
    • Vanuatu
    • Vatican City
    • Venezuela
    • Vietnam
    • British Virgin Islands
    • Isle of Man
    • US Virgin Islands
    • Wallis and Futuna
    • Western Sahara
    • Yemen
    • Zambia
    • Zimbabwe
    • Other
    Press
    Enter
  • 11
    Press
    Enter
  • 12
    Press
    Enter
  • 13
    Press
    Enter
  • 14
    EX: nursing home, group home, prison, jail or military
    Press
    Enter
  • 15
    Press
    Enter
  • 16
    Press
    Enter
  • 17
    Press
    Enter
  • 18
    If you have no symptoms please say N/A or leave blank
    Press
    Enter
  • 19
    -
    Pick a Date
    Press
    Enter
  • 20
    Please select your desired testing solution below. Patient is responsible for verifying that any test is acceptable for their testing needs in regards to employment, travel, etc. The state did not renew our PCR test discount and as such our cost to acquire the cartridges increased substantially. The new price is reflected below.
    prevnext( X )
        My Bag
        0
        My Bag
        Great Product Name
        $20
        Quantity:1
        Size:Small
        RemoveEdit
        Great Product Name
        $20
        Quantity:1
        Size:Small
        RemoveEdit
        Great Product Name
        $20
        Quantity:1
        Size:Small
        RemoveEdit
        Great Product Name
        $20
        Quantity:1
        Size:Small
        RemoveEdit
        ORDER SUMMARY
        Total costUSD
        • Rapid Strep TestThis test is used to detect the presence of Group A strep, this is a throat swab test using the BD Veritor System
          $45.00RemoveEdit
          Back
        • AscencioDx Moleculer Covid TestThis rapid molecular test can be used as verification for travel or for pre-procedure purposes. It also can serve as a confirmatory test for patients who are getting inconclusive results with home tests.
          $65.00RemoveEdit
          Back

          1
          • 1
          • 2
          • 3
          • 4
          • 5
          • 6
          • 7
          • 8
          • 9
          • 10
          Total cost $0.00
          Credit Card - If you do not owe for your selected test (Total Cost reads $0.00) you may click next. Credit card information is only required if payment is required.  
          Press
          Enter
        • 21
          Press
          Enter
        • 22
          Test will take place outside the pharmacy. Please check in at the pharmacy trailer
          Press
          Enter
        • 23
          By signing below I understand that my credit card supplied will be charged in advance for anticipated services. I understand that should I miss or cancel the appointment with less than 24 hours notice that a $15.00 fee will be charged while any cost in excess of that will be reversed for services not ultimately provided. Additionally I understand that my information may be shared with other health care providers in the interest of my personal health care and that of the community. This communication may include but not be limited to contact tracing, therapy discussion quarantine and isolation advice. Vashon Pharmacy works closely with VashonBePrepared and the Medical Reserve Corp on Vashon. Vashon Pharmacy is obligated by law to report all test results to the local health department. I acknowledge that the contact information I provided is accurate and that if information was entered incorrectly I may not receive the needed communication. I attest that I do not hold Vashon Pharmacy or any of its test administrators liable for any harm during the collection of this sample and I completely hold them harmless of any injury of any kind. If for any reason this test cannot be performed by Vashon Pharmacy due to unexpected staff shortages or acts of god and no reasonable accommodation can be made that I will receive a full refund.
          Clear
          Press
          Enter
        • Should be Empty:
        Question Label
        1 of 23See AllGo Back
        close