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
State / Province
Zip code
State
*
Please Select
AL
AK
AZ
AR
CA
CO
CT
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
You may choose a different option if your State is different
County of Residence
*
Please Select
Atlantic
Bergen
Burlington
Camden
Cape May
Cumberland
Essex
Gloucester
Hudson
Hunterdon
Mercer
Middlesex
Monmouth
Morris
Ocean
Passaic
Salem
Somerset
Sussex
Union
Warren
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
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