Rapid Influenza A+B

1
Please complete this form for the Influenza Nasal Swab Test. It is $75 and cannot be processed through insurance. We will provide you documentation to provide to your insurance for potential reimbursement. Results will be provided within 15 minutes.
2
Signature* This field is required.Please read the following statement in its entirety. Due to high testing demand, we do not allow appointment cancellations.*Tests are $75 and non-refundable*These are rapid Influenza A+B 2 Tests. Please verify with your end user if they will accept Rapid Influenza A+B 2 Tests as clearance, if this is intended for purposes such as: work. travel, nursing home, hospital, etc.By signing your name, you agree to our terms that Oakhurst Pharmacy will not be held responsible for any representations.
Clear
3
Appointment* This field is required.
4
Date and Time of Test Confirmation* This field is required.
Date
Year
Month
Day
1
2
3
4
5
6
7
8
9
10
11
12
Hour
00
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
Minutes
PM
AM
PM
5
Name* This field is required.
First Name
Middle Name
Last Name
6
Gender
Male
Female
N/A
7
Birth Date* This field is required.
Month
Day
Year
8
Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curacao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
9
Cell Phone Number* This field is required.
Please enter a valid phone number.
10
Email* This field is required.Required if you would like the results emailed to you
example@example.com
11
Race* This field is required.Required by CDC
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
Other Race
White
12
Ethnicity* This field is required.Required by CDC
Hispanic or Latino
Not Hispanic or Latino
Unknown
13
Rapid Influenza A+B 2* This field is required.
Rapid Influenza A+B 2
14
ICD-10 Code* This field is required.Please stay in your car and pull up to the front of the store if you are symptomatic or have been exposed to someone with COVID. DO NOT COME INSIDE! Please arrive 5 minutes before your appointment and call the store when you have arrived.
Z20.828 - Contact with and suspected exposure to other viral communicable disease (DO NOT COME INSIDE, STAY IN YOUR CAR)
Z11.59 - Asymptomatic, no known exposure, results unknown or negative
15
Attention Customers

Our online payments are currently down please read this message in it's entirety.

To secure your appointment slot please call our pharmacy at 732-531-3784 to make a payment over the phone.

Due to high testing demand, we do not allow appointment cancellations.

*Tests are $75 and non-refundable*

We cannot guarantee your appointment without payment ahead of time.
Should be Empty: