COVID-19 RAPID ANTIGEN & RAPID PCR TEST REQUEST & RESULTS FORM

Please complete one form for each patient that is requesting COVID-19 testing. Include form with specimen submission. By allowing us to collect your information, you are consenting to a Rapid Covid Antigen or PCR test at Southern Drug Company. Southern Drug Company does not bill insurance for this test. Some insurances may reimburse, but reimbursement is not guaranteed.
SOUTHERN DRUG COMPANY

PHARMACY
COVID-19 RAPID ANTIGEN & RAPID PCR TEST REQUEST & RESULTS FORM
Test Performed*

$75 - Rapid Antigen Test - CareStart Rapid Antigen Test for Detection of SARS-CoV-2$149 - Rapid PCR - Accula RT-PCR Molecular Test for Detection of SARS-CoV-2 (NAAT Test)$59 - Antibody Test - FaStep Rapid Antibody test for detection of SARS-CoV-2$99- COVID-19/Influenza A/B Combo Antigen Test
Appointment
Date of Test
Time of Test (Time Scheduled at Southern Drug Company)
PATIENT INFORMATION
First Name*
Last Name*
Date Of Birth*
Gender*

MaleFemale
Address*

Address

Street Address Line 2

CityState

Zip Code
Phone*
Email*
example@example.com
Race - White, Black, Asian, Native Hawaiian/Pacific Islander, American Indian, Multiracial
Ethnicity - Hispanic or Non-Hispanic
Other Important Information (Travel, Passport #, Etc)
QUESTIONNAIRE
1. Does the patient work in a healthcare facility or congregate setting? (e.g., long-term care facility, shelter, prison, jail)*

NoYesIf Yes - Facility Name
2. Employee Occupation
Did the patient work while ill?*

YesNo
5. Reason for Testing:*

TravelSymptomaticExposureWork RequirementOther
Is the Patient Currently Pregnant?*

YesNo
Have you received your COVID-19 Vaccines?

YesNo
Are you fully vaccinated for COVID-19?

YesNo
7. Has patient had a direct exposure to COVID-19?*

YesNoUnsure
If Yes, approximately how many days ago (or what date) were you exposed to COVID 19?
8. Is/was patient symptomatic?*

YesNo
9. If Yes, Date of symptom onset

MonthDayYear
Date
10. If Symptomatic, please check the symptoms you are experiencing now:*

Fever or chillsSore Throat/HoarsenessMuscle or Body AchesCoughCongestion or Runny NoseHeadacheShortness of BreathNausea and/or VomitingNew Loss of Taste or SmellDiarrheaFatigueNone
Is this the patient's first COVID test?

YesNo
Should be Empty:

SOUTHERN DRUG COMPANY

COVID-19 RAPID ANTIGEN & RAPID PCR TEST REQUEST & RESULTS FORM

PATIENT INFORMATION

QUESTIONNAIRE