Community COVID-19 Rapid Antigen Test Appointment Form

Wellness Rx LLC Pharmacy

Rapid COVID-19 Test Appointment Form
This form is to schedule a Rapid Antigen COVID-19 test

Instructions for patient: DO NOT COME INSIDE THE STORE. Call us when you arrive to let us know you are here for your rapid test at 518-589-9500. When instructed, please come to the FRONT porch, turn left and go into the testing room on the side deck. Take a seat in the testing room and wait for the pharmacist to come in to do your nasal swab. Pharmacist or technician will tell you where to wait for your results. Results take 15-20 minutes. After completing this form, you will receive an email confirmation and receipt.
The cost for each rapid COVID-19 antigen test is $64.99. You must pay online when booking your appointment. You can submit your receipt to your insurance company to try to receive reimbursment.
Appointment*
Name of person getting tested*

First Name and Middle InitialLast Name
Parent or Guardian (if minor getting tested:)

First NameLast Name
Patient Age:*
Patient Birthdate*

MonthDayYear
Date
Primary Address*

Street Address

(PO Box or apartment number)

CityState / Province

Postal / Zip Code
County (where you primarily reside)*
(example: Greene, Columbia, Ulster)
Phone Number*
Please enter a valid phone number.
Email (you will receive an email confirmation for your appointment)*
example@example.com
Gender*
Race *
Ethnicity*
Please select
Pregnant or Postpartum*
Reason for testing*
School Information if applicable
School name
School District
Teacher, Student, Other
Was the patient at school in the past 7 days?

yesnoN/A
Employment Information if applicable
Employer Name
Employee Job Title
Employer phone number
Employer Address
City
State
Zip Code
Are you actively displaying symptoms of COVID-19?*
Symptoms onset date if applicable

MonthDayYear
Date

Checkout*

COVID Rapid Test

$64.99

Total

$0.00

Credit Card

Should you schedule an appointment and be unable to make your appointment time please call 518-589-9500 to let us know.

Thank you!
COVID-19 Testing Consent Form

A sample will be collected from you or your child by nasal swab. A trained healthcare professional from Wellness Rx will be collecting the Nasal Swab (front/sides of nose).
Please carefully read the following notice and sign the authorization to test for COVID-19.

I understand that the COVID-19 testing will be conducted with a rapid antibody test, or other acceptable test as ordered by an authorized medical provider or a public health official. I understand that I am not creating a patient relationship with the ordering physician by participating in this testing. I understand the entity performing the test is not acting as my medical provider. Testing does not replace treatment by my medical provider. I assume complete and full responsibility to take appropriate action with regards to my test results and my medical care. I agree I will seek medical advice, care, and treatment from my medical provider or other health care entity if I have questions or concerns, if I develop symptoms of COVID-19, or if my condition worsens. I understand it is my responsibility to inform my health care provider of a positive test result, and that a copy will not be sent to my health care provider for me. I understand that my antigen test result will be available in 15-30 minutes. I understand and acknowledge that a positive test result is an indication that I need to self-isolate to avoid infecting others until I obtain a negative PCR test result. I have been informed of the test purpose, procedures, and potential risks and benefits. I will have the opportunity to ask questions before proceeding with a COVID-19 diagnostic test at the testing site. I understand that if I do not wish to continue with the COVID-19 diagnostic test, I may decline to take the test. If I decline to take the test, I may be unable to participate in certain activities, such as athletic practice or competition. I understand that I may withdraw my consent to participate in testing at any time.
AUTHORIZATION/CONSENT TO TEST FOR COVID-19*

I agree to undergo COVID-19 testingI agree to authorize my child to undergo COVID-19 testing.
Signature for 18 and older or Parent/Guardian*

Clear
Instructions for patient: DO NOT COME INSIDE THE STORE. Call us when you arrive to let us know you are here for your rapid test at 518-589-9500. When instructed, please come to the FRONT porch, turn left and go into the testing room on the side deck. Take a seat in the testing room and wait for the pharmacist to come in to do your nasal swab. Pharmacist or technician will tell you where to wait for your results. Results take 15-20 minutes. After completing this form, you will receive an email confirmation and receipt.
Should be Empty:

Wellness Rx LLC Pharmacy

This form is to schedule a Rapid Antigen COVID-19 test

School Information if applicable

Employment Information if applicable

Credit Card

Should you schedule an appointment and be unable to make your appointment time please call 518-589-9500 to let us know.

COVID-19 Testing Consent Form

Please carefully read the following notice and sign the authorization to test for COVID-19.