COVID TEST Consent Form

COVID Test Consent Form

We are currently offering a FREE rapid antigen test (nasal swab) as well as a $75 PCR test (nasopharyngeal). If you are scheduling a PCR test, please call the pharmacy THE DAY OF your test to pay the $75 fee. The test will be in our alley way, we are the last door on your right. Please give us a call when you're out back and we will come to you for testing
If you have remaining questions, please call us at 620-221-0080.
Section I. Personal Information
Patient's Full Name *

First Name Middle Name Last Name
Date of Birth: *

Month Day Year
Age: *
Phone Number: *
Email: *
Gender: *

Male Female
Are you currently pregnant? *

Yes No Unsure
Ethnicity: *

Hispanic or Latino Non Hispanic/Latino Unknown Prefer not to answer
Race: *

African American American Indian Asian Caucasian Native Hawaiian/Other Pacific Islander Prefer not to answer
Address: *

Street Address Line 2
Primary Care Doctor: *
Doctor City/State: *
My preferred test is: *

Rapid Test (FREE, nasal swab - results in 15 minutes) Rapid PCR Test ($75, nasal swab - results in 30 minutes)
Is this your first Covid test? *

Yes No
Do you work in a healthcare setting? *

Yes No
Have you had a COVID vaccine? *

Yes, Pfizer Yes, Moderna Yes, Johnson&Johnson Yes, but only one of two doses of mRNA vaccine (Moderna/Pfizer) No
If you have received a COVID vaccine please list the date of your last dose *

Month Day Year
Date
Have you had an exposure to COVID-19? *

Yes No Unsure
Approximately how many days ago were you exposed?
What symptoms are you experiencing now? Please check all that apply. *

Fever or Chills Cough Shortness of breath Fatigue Muscle or body aches Headache New loss of taste or smell Sore throat/hoarseness Nausea or vomiting Diarrhea Congestion or runny nose No Symptoms
Appointment *
Section IV. Signature

By signing this form, I give consent for Graves Drug to send my testing results to the Kansas State Department of Health and Welfare and verify that I am not being tested for travel or any other reasons stated above to be not included in the state of Kansas community testing partner funding.
*

I understand that this test is performed AT THE CAR. I will NOT enter the pharmacy for my test.
Signature of Person to Receive COVID test (or Signature of Parent/Guardian if Patient is < 18 yo) *

Clear
By clicking the "Submit" button below, you certify that the above information is correct and accurate to the best of your knowledge. All information is confidential and is accessed only via a secure, encrypted interface.
Should be Empty: