• 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!).

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

     

    DO NOT CONTINUE!

  • General Information

     Required fields are marked with an asterisk (*).

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  • Contact Information

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

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  • Demographics

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

  • Other Information

  • 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

    -- For Pharmacy Use Only BD Veritor Testing --
  • BD Veritor Testing Information  rev:01/06/2022

    {name}

    Lot# 1355978  Expiration Date: 02/03/2023

    Date Test Performed: __________________

    Time Test Performed: __________________

    Performed by (Circle):     Richard McCoy(Pharmacist)   

                                          Margaret McCoy(Pharmacist)

                                          Other: _______________________

     Veritor Test Results

    Flu A:      _________   Negative     _________ Positive

    Flu B:      _________   Negative     _________ Positive

    Covid-19: _________  Negative     _________ Positive

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