Rapid Testing Registration

Parkway Pharmacy PCR Testing Registration

35 Minute turn around time
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Gender

MaleFemalePrefer not to answer
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com
Travel and Exposure
Have you had close contact with someone who had a confirmed case of Covid-19?

YesNo
Are you a resident in a special setting where the risk of Covid-19 transmission may be high? (This may include long-term care, correctional and detention facilities; homeless shelters; assisted living facilities and group homes)

YesNo
In the last 72 hours, have you experienced any of the following syptoms (check all that apply?)

FeverChillsShortness of Breath / WheezingFatigueMuscle or body achesHeadacheNew loss of taste or smellSore ThroatCongestion or runny noseNauseaVomitingDiarrheaNone
Federal Government Mandated Questions:
Have you been given a COVID-19 vaccine in the last 9 months?

YesNo
Is this your first time taking a COVID-19 test?

YesNo
Why are you taking a covid-19 test?

Exposed to someone and I am experiencing symptomsExposed to someone and I am NOT experiencing symptomsTraveling and need a testRequired to get one prior to a medical procedure
Have you tested positive on an at home Rapid Antigen test in the last 5 days

YesNoHave not checked
Signature

Clear
Today's Date

MonthDayYear
Date

My Products

PCR Test -35 Minute Turn AroundThis test in administered and processed in house. The results will come 35 minutes after culturing begins. Some delay can occur if other tests are running.

$169.00

Total

$0.00

Credit Card

Please note: All tests are self pay. We will provide you with documentation and claim forms to submit to your insurance company for reimbursement.
Should be Empty:

Parkway Pharmacy PCR Testing Registration

Credit Card