Cognivue Cognitive Function Screening Request Form

Tarrytown Pharmacy Cognivue Cognitive Function Screening Patient Request Form

Please read below carefully and fill out the form to the best of your knowledge.
Select Assessment:*
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Cognivue Cognitive Function Screening and AssessmentCognitive Function Assessment - 10-minute assessment test performed at Tarrytown Pharmacy
$49.99

Total

$0.00
Please Schedule your Cognitive Function Screening*

Patient Demographic Information
Patient Name (Must include Middle Initial)*

FirstNameMiddle InitialLastName
Patient Date of Birth*

MonthDayYear
DateOfBirth
Patient Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Patient Gender: (M: Male and F: Female)*

MF
Cell Phone Number: (Please double check for accuracy)*
Please enter a valid phone number.
Primary Phone Number: (Please double check for accuracy)*
Please enter a valid phone number. Only enter the numbers no ( ) or dashes
Patient Email*
example@example.com

Does the Patient have Insurance?*

YESNO (uninsured)
If you answered YES to the question above, please select which type of insurance you have: (Select All That Apply)

Medicare Part A/B (Red, White, & Blue Card for patients over the age 65)Medical Insurance (Coverage for medical visits)
Please Enter Medicare Part B ID# (red, white, and blue card for patients over 65)
*if you are not over 65 or do not have part B, enter "n/a".
Please upload a picture of your medical insurance card or Medicare Card (Front and Back)*

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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
Date of Form Completion*

MonthDayYear
Date
Consent Signature of patient or authorized representative*

Clear

Payment Methods

Debit or Credit Card

First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Please click one of the PayPal options to complete payment and submit the form.

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Tarrytown Pharmacy Cognivue Cognitive Function Screening Patient Request Form

Patient Demographic Information

Pre-Screening Questions

Attestation, Consent, and Signature