New Patient Intake Form Ver 2.2P

Lopez Island Pharmacy (360)468-2616 Fax (360) 468-3825

Covid-19 & Flu Testing Appointment

BD-Veritor Quick Antigen

rev: 01/10/2023 HIPAA Compliant ver 2.0

Please only fill out this form after you have made an appt.

This form is for a Covid-19 & Flu Test that we administer in the parking lot (NOT for the "Free at Home" Covid-19 tests).

These tests are FREE of charge but we are not allowed to test for travel or event attendence

Your test sample will be done in your car, we will do our best to watch for you when your appointment time is due. If we don't see you either call, text or honk your horn(gently!).
I certify that this test is NOT for travel reasons or event attendance.*

YesNo
We're sorry but you do not qualify for this free testing.

DO NOT CONTINUE!
General Information

Required fields are marked with an asterisk (*).
Have you received ANY Covid Vaccinations?

YesNo
How many Covid-19 vaccinations have you received?

12341 ONLY J&J
Are you having ANY symptoms?*

YesNoUnsure
Are you experiencing any of the following, check all that apply

Fever over 100.4FFeeling feverishChillsCoughShortness of BreathDifficulty BreathingFatigueMuscle or body achesHeadachesNew loss of tasteNew loss of smellSore throatNasal congestionRunny NoseNauseaVomitingDiarrhea
Date of symptom onset

MonthDayYear
Date
Name*

First NameMiddle NameLast NameSuffix
Role

ResidentVisitorStaffStudent
Preferred Language

EnglishSpanishUnknown
Birthdate*

MonthDayYear
Date
Contact Information

You're responsible for entering the correct contact information, following applicable federal and state laws.
Primary Phone Number*

Area CodePhone Number
Phone Type*

MobileLandline
Email
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Demographics

This information is collected as part of public health efforts to recognize and address inequality in health outcomes.
Race*

American Indian/Alaskan NativeAsianBlack/African AmericanNative Hawaiian/other Pacific IslanderWhiteOtherPrefer NOT to answer
Are you Hispanic OR Latino

YesNo
Sex Assigned at Birth*

MaleFemaleNon-binaryPrefer NOT to answer
Are you pregnant?`

YesNoUnsure
Other Information
Are you a resident in a congregate living setting? For example: nursing home, group home, prison, jail, or military a question

YesNoUnknown
Are You a Health Care Worker

YesNoUnknown
After pressing "Submit" you will get a green check mark that the form has been submitted.

If you have not made an appointment yet, please go to our web site, www.lopezislandpharmacy.com and make an appointment for testing or call for help if you do not see any appointments.

Lopez Island Pharmacy Covid/Flu Testing