rapid test online Form

What type of test you are requesting? *

PCR (molecular non-rapid ) Rapid (Antigen based on availability)

PCR TEST:

This is not a rapid test. Currently, due to extremely large numbers of tests, the lab informed us that it can take 72 hours or longer for results to be ready. The pharmacy is a collection site for tests, please do not call the pharmacy to inquire about test results. If the test result is inconclusive or invalid, the test will need to be repeated. Please present your insurance card and valid ID at your appointment.

RAPID ANTIGEN TEST:

The cost for the rapid antigen tests is $69. You will be provided an invoice to submit to your insurance for reimbursement. Rapid test currently can take up to 2 hours. Please pull up to our drive-thru window at your appointment time, to perform the test. Results can be either emailed or texted to you. Please bring a valid government ID to your appointment.

NOTE:

The pharmacy does not handle inquires about the PCR test, over the phone. Any inquiry can be e-maild to Pharmacist@caringwellnesspharmacy.com

Location: 1097 Loudon Rd. Cohoes NY 12047

Name *

First Name Last Name

Date of Birth *

Date

Gender *

Male Female Other or prefer not to answer

Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Cell Phone Number *

Please enter a valid phone number.

Primary Care Doctor

Email

example@example.com

Do you have any COVID 19 symptoms *

Yes No

What are your symptoms *

Fever Cough Shortness of Breathe Headache Fatigue Other

Date of onset of symptoms *

Date

Did you have known contact with another COVID-19 positive case? *

Yes No

Are you a healthcare worker or someone who interacts directly with the public *

Yes No

Have you travelled 14 days prior to testing *

Yes No

Location *

Depart/Return Date *

Date

Are you fully vaccinated (2 weeks since last dose)? *

Yes No

What vaccine did you receive?

pfizer moderna J&J Other

Appointment for PCR test *

Appointment for RAPID ANTIGEN test *

I give permission to Caring Wellness Pharmacy to perform my COVID 19 testing and report my results to NY state as required by law.

Signature *

Clear

Appointment for PCR or Rapid Antigen* COVID 19 test