Covid Testing Form

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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
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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

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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.

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Name* This field is required.
First Name
Last Name
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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
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Preferred Language
English
Spanish
Other
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Date of Birth* This field is required.Please type using MM-DD-YYYY format
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Phone Number* This field is required.
Please enter a valid phone number.
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Email
example@example.com
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Address* This field is required.
Street Address
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Country
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Race* This field is required.
American Indian/Alaskan Native
Asian
Black/African American
Native Hawaiian/other Pacific Islander
White
Other
Prefer not to answer
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Are you Hispanic or Latino?
Yes
No
Prefer not to answer
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Sex Assigned at Birth* This field is required.
Female
Male
Non-Binary
Prefer not to answer
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Are you a resident in a congregate living setting?EX: nursing home, group home, prison, jail or military
yes
no
unknown
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Are you a health care worker?
Yes
No
Unknown
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What is your vaccination status?
Not Vaccinated
Completed Initial series (2 doses mRNA or 1 dose J&J) >6 months ago
Completed Initial series (2 doses mRNA or 1 dose J&J)
Completed Initial series and have received booster dose(s)
Rather not say
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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
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Date of Symptom OnsetIf you have no symptoms please say N/A or leave blank
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Date of symptom onset
Date
Month
Day
Year
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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. 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.
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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
$45.00Edit
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.
$65.00Edit
Back
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Quantity
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.
First Name
Last Name
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Are you currently pregnant?
Yes
No
Prefer not to answer
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Please Select a Testing Appointment* This field is required.Test will take place outside the pharmacy. Please check in at the pharmacy trailer
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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.
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