Covid Testing Form

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. Unfortunately, as a pharmacy we are not yet able to bill medical insurance for these services. We are continuing to work towards billing insurance and are hopeful it will be possible at some point in 2022.

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
2
Types of tests offered by Vashon Pharmacy and the associated out-of-pocket cost of each.

Rapid-Antigen - COVID 19 - Free (paid for by DOH while supplies last)

Rapid-PCR - COVID 19 (Travel/Medical/Event) - $125 (Out of Stock)

Rapid Covid Antibody Test - $15

Rapid Flu A+B - $45

Rapid Strep - $45

Everlywell At-Home Mail-in PCR - Free (Paid for by DOH, typical turnaround time is typically 2-4 days, patient will need to fill out information with everlywell to register their own kit)

Click next/arrow below to proceed
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 to the mobile unit.

Click next/arrow below to proceed
4
Name* This field is required.
First Name
Last Name
5
Which role best describes you in relation to Vashon, WA?
Resident of Vashon
Visiting Vashon
Live off island but work on Vashon
I am a student
6
Preferred Language
English
Spanish
Other
7
Date of Birth* This field is required.Please type using MM-DD-YYYY format
8
Phone Number* This field is required.
Please enter a valid phone number.
9
Email
example@example.com
10
Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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
Curacao
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
Country
11
Race* This field is required.
American Indian/Alaskan Native
Asian
Black/African American
Native Hawaiian/other Pacific Islander
White
Other
Prefer not to answer
12
Are you Hispanic or Latino?
Yes
No
Prefer not to answer
13
Sex Assigned at Birth* This field is required.
Female
Male
Non-Binary
Prefer not to answer
14
Are you a resident in a congregate living setting?EX: nursing home, group home, prison, jail or military
yes
no
unknown
15
Are you a health care worker?
Yes
No
Unknown
16
Are you experiencing any of the following symptoms?* This field is required.
No Symptoms
Fever over 100.4F
Feeling Feverish
Chills
Cough
Shortness of Breath
Difficulty Breathing
Fatigue
Muscle or Body Aches
Headache
New loss of taste
New loss of smell
Sore Throat
Nasal Congestion
Runny Nose
Nausea
Vomiting
Diarrhea
17
Date of Symptom OnsetIf you have no symptoms please say N/A or leave blank
18
Date of symptom onset
Date
Month
Day
Year
19
Are you currently pregnant?
Yes
No
Prefer not to answer
20
Available Tests* This field is required.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.
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
TaxUSD
SubtotalUSD
Total costUSD
Rapid Antigen Point of Care TestThis test is administered or overseen by a provider using the BD Veritor system. This is most accurate when a patient has COVID-19 Symptoms
$Free+Edit
Back
Rapid PCR Point of Care TestThis is a rapid PCR (gold standard for testing) that can be used as a valid test for travel on airlines, through borders (where accepted) and for pre-surgery or event screening. A valid test result will be supplied within 12 hours of test. This test does not work for Hawaii travel.
$125.00+Edit
Back
COVID Antibody TestThis test uses a small blood sample to detect the presence of antibodies in the system. This DOES NOT indicate current positive or negative infection.
$12.00+Edit
Back
Rapid FLU A+B TestThis test is used to detect for presence of influenza infection - This also uses the BD Veritor system.
$45.00+Edit
Back
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
$45.00+Edit
Back
Everlywell Mail-IN PCR TestThis test is paid for by Washington Dept of Health. It is a PCR test that is performed at home and mailed via UPS - Typical turnaround time is 2-4 days for results.
$Free+Edit
Back
Total cost $0.00
Credit Card
First Name
Last Name
21
Please Select a Testing Appointment* This field is required.Test will take place outside the pharmacy. Please check in at the pharmacy trailer
22
Please read and sign below - click submit to complete signupBy 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
Should be Empty: