PCR COVID Test Smith Brothers Drug Co.

Smith Brothers Drug Co.

This is a healthcare provider MONITORED Point of Care Test. There is a $60 processing fee (after insurance) for PCR Tests . At this moment we are asking that ALL patients do not enter the store. Please contact the pharmacy at the number below when you are parked outside. If you have any questions/concerns please call (856) 779-8300. If you are unable to find an appointment time that works for you please call the number above to see if we have emergency appointments available.
Name *

First Name Last Name
Date of Birth *

Month Day Year
Date
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number *
Please enter a valid phone number.
Gender *
Race *
Ethnicity *
Email *

Confirmation Email This must be unique for each patient requesting a vaccine to get confirmation e-mails.
COVID-19 Testing Questionnaire
Type of Test Requested *
Reason for testing

Symptoms (Fever, Chills, Cough, etc) Contact/Exposure Travel Re-test/Return to work or school
Available Appointment Times *
Insurance / Coverage Information
Card Information for Private/Commercial Insurance (located on front or back of card)

Health Insurance Company Name
Health Insurance ID# Member ID
If Un-insured: I attest that I do not have any insurance.
Social Security Number Required if uninsured SSN
I certify that I am the Patient or guardian of a patient receiving a EUA COVID-19 test. I give my consent to the health care provider Smith Apothecary Corp, as applicable to administer the test(s) I have requested above. I understand that it is not possible to predict all possible side effects or complications associated with receiving these tests and all test results must be used as a component along with the advice and guidance of your healthcare provider. Positive test results should be brought to the attention of your medical doctor and used with their professional judgement as a course of treatment. Negative results do not mean that you should not follow up with your medical doctor if your condition does not improve or worsens. I acknowledge that I have had a chance to ask questions and that such questions were answered to my satisfaction. On behalf of myself, my heirs, and personal representatives, I hereby release and hold harmless Smith Apothecary Corp, as applicable, its staff, agents, successors, divisions, affiliates, subsidiaries, officers, directors, contractors, and employees from any and all liabilities or claims whether known arising out of, in connection with, or in any way related to the administration of the test(s) listed above. I authorize Smith Apothecary Corp, as applicable to release any medical or other information to my health care professionals, as necessary with respect to the test(s) listed above. *

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Payment must be made via credit card. Due to high demand appointments are non refundable and no cancellations are allowed. *

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PCR COVID-19 Test PCR COVID-19 Test : Results in APPROXIMATELY 24 to 48 hours
$ 60.00 Quantity

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$ 0.00

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Smith Brothers Drug Co.

COVID-19 Testing Questionnaire

Insurance / Coverage Information