• Tarrytown Pharmacy Cognivue Cognitive Function Screening Patient Request Form

    Please read below carefully and fill out the form to the best of your knowledge.
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    Cognivue Cognitive Function Screening and Assessment Product Image
    Cognivue Cognitive Function Screening and AssessmentCognitive Function Assessment - 10-minute assessment test performed at Tarrytown Pharmacy
    $49.99
      
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  • Patient Demographic Information

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  • Pre-Screening Questions

    Please answer to the best of your knowledge
  • Attestation, Consent, and Signature

  • I have requested the pharmacy to provide a Cognitive Screening and attest to the following:

    • This Cognitive Function Assessment does not diagnose and is a screening tool
    • I understand that Cognitive Function can increase and decrease based on a variety of factors, and results can change after each assessment
    • This appointment is non-refundable
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  • Please click one of the PayPal options to complete payment and submit the form.

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