Paxlovid Screening form Plumsted Pharmacy

Plumsted Pharmacy Paxlovid Screening

This is a screening form for Paxlovid (COVID-19 Therapeutics). A pharmacist will review this information to determine if treatment is appropriate. Please upload all necessary information in this form. If you have any questions/concerns please call 609-758-8829. If you are unable to find an appointment time that works for you please call the number above to see if we have emergency appointments available. There is a charge of $50 for a Paxlovid Screening Appointment, this cost is included with a RAPID COVID-19 test option. Currently we are unable to accept insurance for screening appointments, however if Paxlovid is prescribed by our pharmacist, there will be no cost for the medication itself.
Name*

First NameLast Name
Date Of Birth*

MonthDayYear
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Patient Gender *
What is your current weight ?*
Must be 88lbs or greater to be prescribed Paxlovid
Email *

Confirmation Email.
If you have a primary care doctor please provide their information.
Primary Care doctor's name
Primary Care doctor's phone Area Code Phone Number
Health Screening Questionnaire
Do you have any of the following symptoms?*

Fever,ChillsCoughing, WheezingNausea/Vomitting/DiarrheaRunny Nose, CongestionSore ThroatLoss of Smell or TasteNo Symtoms of COVID-19
When did these symptoms start? *

MonthDayYear
Symptom onset must be within 5 days to be eligible for Paxlovid.
Have you tested positive for COVID-19 within the past 5 days*
If you do not have a positive COVID-19 test or staus is Unkown you will be required to select the RAPID COVID-19 PLUS Screening Option
Please upload a copy of your recent COVID-19 Test

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This is required for dispensing. If you do not have a test please complete our COVID-19 Testing form
Cancelof
Do you have any allergies ?*

Yes, I have allergiesNo known allergies
Please list your allergies
Do you have access to your "blood work"/Labs drawn in the past 12 months?*

YesNo
Please Upload a copy of your most recent laboratory blood work

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Cancelof
We will reach out to your doctor to determine your kidney and liver function as required by Paxlovid prescribing authorization.
Primary Care doctor's name Type a label
Primary care doctor's phone Area Code Phone Number
Do you (or have you been told by a healthcare provider) that you have a history of any of the following medical conditions?*

Moderate to Severe Kidney DysfunctionSevere Liver (Hepatic) DysfunctionNo, I do not have Moderate to Severe kidney or Liver Dysfunction
Based on your medical history provided please contact your primary care doctor for advanced screening for Paxlovid.
Do you have any chronic medical conditions?*

YesNo
Please list your current Medical Conditions
Do you take any medications?*

YesNo
Please list your current medications
Available Appointment Times for pharmacist consult (telephone)
Available Appointment Times (Telephone Consult)

I certify that I am the Patient or guardian of a patient receiving a Paxlovid under EAU FDA authorization. I give my consent to the health care provider Plumsted Apothecary Inc, as applicable to administer the test(s) I have requested above as well as complete a medical history and screening for the prescribing of Paxlovid if clinically appropriate. I understand that it is not possible to predict all possible side effects or complications associated with receiving these tests and/or treatment and all test results must be used as a component along with the advice and guidance of your healthcare provider. I attest that all the information provided is to the best of my knowledge correct. Our pharmacists will screen for clinical appropriateness and drug interactions with this information provided and will reach out to your primary health care team if necessary for consultation. Positive test results should be brought to the attention of your medical doctor and used with their professional judgement as a course of treatment. Negative results do not mean that you should not follow up with your medical doctor if your condition does not improve or worsens. I acknowledge that I have had a chance to ask questions and that such questions were answered to my satisfaction. On behalf of myself,my heirs, and personal representatives, I hereby release and hold harmless Plumsted Apothecary Inc, as applicable, its staff, agents, successors, divisions,affiliates, subsidiaries, officers, directors, contractors, and employees from any and all liabilities or claims whether known arising out of, in connection with, or in any way related to the administration of the test(s) listed above.I authorize Plumsted Apothecary Inc, as applicable to release any medical or other information to my health care professionals, as necessary with respect to the test(s)/treatment listed above.*

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Payment must be made via credit card. Due to high demand appointments are non refundable and no cancellations are allowed. *

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Plumsted Pharmacy Paxlovid Screening

Health Screening Questionnaire

Based on your medical history provided please contact your primary care doctor for advanced screening for Paxlovid.