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 name Middle name Last name
What is the purpose of your test?

Travel Symptoms Exposure (without symptoms)
Date of birth (MM/DD/YYYY) *

Month Day Year
Date
Primary Phone Number *
Phone Type *

Mobile Landline
Would you like to receive your results via email?

Yes No
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

City

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 Native Asian Black or African American Native Hawaiian or other Pacific Islander White Prefer not to answer Other race (specify)
Ethnicity *

Hispanic or Latino Not Hispanic or Latino Unknown
Sex *

Female Male Non-binary Prefer not to answer
Are you a resident in a congregate living setting? Example: nursing home, group home, jail, miltary, etc.

Yes No Unknown
Are you a healthcare worker?

Yes No Unknown
Select the most appropriate status below regarding pregnancy *

Pregnant Postpartum Unknown Neither pregnant nor postpartum
Do you have any symptoms? *

Yes No Unknown
Date of symptom onset

Month Day Year
Date
List your symptoms (if applicable)

Fever or chills Cough Shortness of breath or difficulty breathing Fatigue Muscle or body aches Headache New loss of taste or smell Sore throat Congestion or runny nose Nausea or vomiting Diarrhea
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