RT-PCR COVID-19 Test Appointment and Consent Form Family Pharmacy

COVID-19 Test Appointment & Consent Form

RT-PCR COVID-19 Testing; Same Day Results; Cost $149
Patient Name*

First nameMiddle nameLast name
What is the purpose of your test?

TravelSymptomsExposure (without symptoms)
Date of birth (MM/DD/YYYY)*

MonthDayYear
Date
Primary Phone Number*
Phone Type*

MobileLandline
Would you like to receive your results via email?

YesNo
We will email you the results of your test via an unsecured email from Family Pharmacy that is not HIPAA compliant. If you prefer, we will have a printed copy of your results available for pick up at the pharmacy.*

I would like to receive my test results via an unsecured email from Family Pharmacy that is not HIPAA Compliant.I DO NOT want to receive my test results via an unsecured email; I will come by the pharmacy to receive a hard copy.
Email address*
example@example.com
Address*

Street Address (and unit/apt # if applicable)

Street Address Line 2

CityState / Province

Zip code
State*
You may choose a different option if your State is different
County of Residence*
You may choose a different option if your County is different
Race (select all that apply)*

American Indian or Alaska NativeAsianBlack or African AmericanNative Hawaiian or other Pacific IslanderWhitePrefer not to answerOther race (specify)
Ethnicity*

Hispanic or LatinoNot Hispanic or LatinoUnknown
Sex*

FemaleMaleNon-binaryPrefer not to answer
Are you a resident in a congregate living setting? Example: nursing home, group home, jail, miltary, etc.

YesNoUnknown
Are you a healthcare worker?

YesNoUnknown
Select the most appropriate status below regarding pregnancy*

PregnantPostpartumUnknownNeither pregnant nor postpartum
Do you have any symptoms?*

YesNoUnknown
Date of symptom onset

MonthDayYear
Date
List your symptoms (if applicable)

Fever or chillsCoughShortness of breath or difficulty breathingFatigueMuscle or body achesHeadacheNew loss of taste or smellSore throatCongestion or runny noseNausea or vomitingDiarrhea
Signature*

Clear
I understand I am responsible for the cost of this test at $169. Family Pharmacy cannot submit a claim directly to your insurance. We will provide you with an invoice for your purchase, although we cannot guarantee your insurance carrier will reimburse you for the cost of the test.*

Yes, I understand I am responsible for the cost
Should be Empty:

COVID-19 Test Appointment & Consent Form