Covid Testing and Consent

COVID TESTING AND CONSENT
Appointment
Name

First NameLast Name
Birth Date

MonthDayYear
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Type of test requested
Race

American IndianAsianBlack or African AmericanWhiteOther
Ethnicity

Hispanic or LatinoNon Hispanic or LatinoUnknownOther
Have you had a direct exposure to COVID-19?

YesNoUnsure
What symptoms are you experiencing now? (Select all that apply)

No SymptomsFever or ChillsCoughShortness of breathFatigueMuscle or body achesHeadacheLoss of smell or tasteSore ThroatCongestion or runny noseNauseaDiarrheaOther
How many days have you been experiencing symptoms?
**By signing below, I give consent to Brundage's Waymart Pharmacy to perform COVID-19 testing and to submit my results to the Pennsylvania Department of Health.

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COVID TESTING AND CONSENT