Rx3 Pharmacy COVID-19 Testing Appointment Request

RX3 COVID-19 Testing Appointment Request
Agree to Terms & Conditions

By signing below you agree:
1. You are 18 years or older, or the parent or legal guardian of a minor patient 3 years or older.

2. You are not experiencing severe symptoms such as severe shortness of breath, continuous pain or pressure in the chest, or persistent fever greater than 102ºF.

**If you are experiencing severe symptoms, please seek medical attention immediately**

3. You acknowledge that you or the minor patient's information will be used as described in the Rx3 Pharmacy Notice of Privacy Practices.

4. You agree to receive email communications that contain information about you or the minor patient's eligibility for COVID-19 testing and COVID-19 testing appointments.

By selecting 'I agree' below, you also have read and accept Rx3 Pharmacy Terms of Use.
Do you agree to the terms outlined above?*

I acceptI decline
Name*

First NameLast Name
Schedule a time*
Patient gender*
Patient date of birth*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Available Tests, please select one.*

Rapid PCR Test (results in 20 minutes, $180) TRAVEL ONLYRapid Antigen Test (results in 15 minutes, $135)
Driver's License State
Driver's License Number
*

I understand that this information will be provided to U.S. Department of Health and Human Services Uninsured program and the offsite laboratory.
*

Authority to Act: I certify that I am the patient or parent of the minor patient.
Please stay in your vehicle*

DO NOT ENTER THE PHARMACY. Pull around back and park in one of the designated testing spaces. Call us at 804-717-5000 and inform us that you are here.
Signature*

Clear
DO NOT ENTER THE PHARMACY

Pull around back and park in one of the designated testing spaces.

Call us at 804-717-5000 and inform us that you are here.

After hitting submit you will pay for your test.

Please note if you do not pay for your test before your appointment, your appointment time will not be held.
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RX3 COVID-19 Testing Appointment Request

Agree to Terms & Conditions