Covid-19 Testing

Covid-19 Testing Registration
For FREE lab-based PCR test (2+ days), please click on the link below to begin.

Covid-19 Antigen PCR lab-based test *NO COST TO YOU*

**Every individual, including children, MUST be registered for their own account, in their own name. Otherwise, your test may not be processed. Save your user ID and Password created during registration! You will need this to get your test results once they are ready.**

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For Rapid Test options, please answer all questions below:
Which rapid test(s) would you like to schedule? (result ~ 1 hr) *

Covid-19 Rapid Antigen test -$35 Covid-19 Rapid NAAT Molecular test - $95 (for travel) Covid-19 Rapid Antibody test - $25
Personal Information for Rapid test(s) only:
First Name: *
Middle Name:
Last Name: *
Role: *

Resident Visitor Staff Student
Date of Birth *

Month Day Year
Date
Phone Number *
Please enter a valid phone number.
Email *
example@example.com
How would you like to receive your test result? *

Email Text
Street Address *
Apt
City *
State *
Zip *
County
Race *

White Black/African American American Indian/Alaskan Asian Native Hawaiian/other Pacific Islander Other Prefer not to answer
Ethnicity *

Hispanic or Haitian origin NOT Hispanic or Haitian origin
Gender assigned at birth *

Male Female Other Prefer not to answer
Are you currently pregnant?

Yes No Prefer not to answer
Are you a resident in a congregate living setting? E.g.: nursing home, group home, prison, jail or military. *

Yes No Unknown
Are you a healthcare worker? *

Yes No Unknown
Are you feeling well today? *

Yes (No symptoms) No (test at curbside or parking lot)
If answered "NO" above, what symptoms are you experiencing?

Fever over 100.4 F Feeling feverish Chills Cough Shortness of breath Difficulty breathing Fatigue Muscle or body aches Headache New loss of taste New loss of smell Sore throat Nasal congestion Runny nose Nausea Vomiting Diarrhea

Signature:
State Driver License or ID #:
SSN or Passport #:
Other:
This testing form uses eTrueNorth Laboratory and/or onsite's testing services to manage COVID-19 testing and reporting. As a User accessing or using JotFrom (Application) provided by Pharmedico Pharmacy, you acknowledge and agree that you are solely responsible for and shall abide by these Terms of Service, as well as any relevant sections of Pharmedico’s Privacy Policies (collectively, Terms).

Sign digitally with your mouse by clicking and dragging to form your signature.
Signature

Clear
Date *

Month Day Year
Date
Appointment
*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.
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Covid-19 Testing Registration

Personal Information for Rapid test(s) only: