Influenza Rapid Diagnostic Test Screening Form

Rapid Influenza Tests are by appointment. You will be asked to schedule your appointment at the end of this form. 

Appointments must be booked at least 5 minutes in advance.

I have read, or have had read to me, the written information regarding the influenza diagnostic test being administered. By signing below, I signify that I agree to allow those pharmacists affiliated with the pharmacy named above to administer the influenza test for a fee of $40.00. This assessment does not constitue a medical diagnosis. Negative results do not preclude Influenza infection and should not be used as the sole basis for treatment. I understand the test that I am receiving is a rapid diagnostic test using antigens. Antigen tests look for viral proteins, which are highly specific, meaning that if you test positive, you are very likely infected. However, there is a higher chance of false negative with antigen tests, which means that a negative result cannot definitively rule out an active infection. If you have a negative result on an antigen test but have a recent exposure to Influenza, or are displaying many of the symptoms, you may wish to take a PCR test to confirm your result. I have had the opportunity to ask questions that were answered to my satisfaction. I certify that I am at least 18 years old and hereby give my consent to the pharmacists of this Pharmacy to administer the influenza diagnostic test. If under 18 years old signature by parent or guardian is required. I understand that by signing below I am responsible for payment of this diagnostic test.