SPF Strep Test Consent Form

OUT OF STOCK

Salida Pharmacy and Fountain is currently out of rapid strep tests.

We expect to receive more tests in the coming days. If you would still like to receive a test when they come in please continue to complete the form and we will call you when they are available.
Group A Strep Test Screening Form
Rapid Group A Strep Test 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.
Medicare Part B Information

Please insert your Medicare Part B information (Red, Whit, and Blue card)
Medicare Part B number
Medicare Part B start date
Colorado Medicaid Information

Please insert the information from your CO medicaid card
CO medicaid number
Letter + six numbers
Insurance Card Information

Please insert the information from your insurance card
BIN
PCN
ID number
Group number
Patient Name*

First NameMiddle NameLast Name
Date of Birth*

MonthDayYear
Date
Age*
Gender*

FemaleMale
Race/Ethnicity*

Caucasian/WhiteAfrican AmericanHispanicAsianAmerican IndianPacific IslanderOther
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Patient Phone Number*
Email Address
example@example.com
Primary Care Provider (PCP) Name*

First NameLast Name
Primary Care Provider (PCP) Phone Number
Please enter a valid phone number.
Please List Current Medications and/or Supplements You Are Taking*
Do You Have any Drug Allergies:*

YesNo
Please List Your Drug Allergies AND What Type of Reaction You Have
Please check below if any of these apply to you. If so you are considered HIGH RISK*

Over 65CancerChronic Kidney DiseaseCOPDSmokerHeart ConditionImmunocompromisedObesitySickle Cell DiseaseType 2 DiabetesI have none of these conditionsOther: _____________________________________
Do you have a history of Rheumatic Fever?*

YesNo
Are you pregnant?*

YesNo
Current Symptoms

For Patients: The following questions will help us determine the severity of your illness and recommendations we can make. If a question is not clear, please ask us to explain it.
Please check below if any of these apply to you.*

Fever >100.4 FSore throat, pain when swallowingRed/swollen tonsilsTiny, red spots on roof of mouthSwollen lymph nodes (front of the neck)CoughHoarsenessRunny NoseRed and/or itchy eyesDiarrheaNO Symptoms
How long have you had symptoms?*
What actions have you taken to date?*
Consent to Testing
I hereby authorize the pharmacist from Salida Pharmacy and Fountain to perform a Group A Strep Rapid Test. I authorize the pharmacists to maintain a copy of this signed form. I indemnify the organizing body and all persons connected with them from any and all claims that may result from my voluntary participation in the tests. By signing below, I signify that I agree to allow those pharmacists affiliated with the pharmacy named above to administer the strep test for a fee of $35.00. I understand that my insurance might not reimburse the fee for the test and hold the pharmacy and pharmacist harmless for any fees not reimbursed. This assessment does not constitue a medical diagnosis. Negative results do not preclude Group A Strep 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 strep, or are displaying many of the symptoms, you may wish to take a PCR test to confirm your result. A PCR test looks for the presence of the virus' genetic material. PCR tests are highly accurate, but can take days to a week to get the results. The antigen test that you are receiving today is most accurate if you are symptomatic and within the first five days of symptoms.
I understand that if my results are positive, the pharmacist may be able to prescribe treatment or will refer you to follow-up with my Primary Care Provider.*

Yes
Form completed by*

First NameLast Name
Representative name (if applicable)

First NameLast Name
Signature of Person Receiving the Testing (or Parent/Guardian of person < 18 years old)

Clear
Do you have medical insurance? (SPF is in network with a select few insurance plans and we might be able to bill your insurance)

YesNo
If yes, please upload a picture of your insurance card.

Cancelof
Pharmacy Use Only

Do not complete the below questions
Name / NPI Pharmacist (Signature)

Lucas Smith, 1609283837Emily Henderson, 1801178017Anthony Urban
Temperature (F)*
Scoring

Absence of cough (1 point)History of fever >100.4 F (1 point)Presence red/swollen tonsils (1 point)Swollen lymph nodes (1 point)
Total Score

0-1 Strep test & antibiotic therapy are not indicated.2-3 Strep test indicated (if positive, antibiotic therapy indicated)Greater/equal to 4 - Consider antibiotic treatment
Status Strep A-Flip Group A Strep TEST RESULT*

POSITIVENEGATIVE
Status Strep A-Flip Group A Strep Lot*
Status Strep A-Flip Group A Strep Exp*
BP
Pulse
Pharmacotherapy Plan
Initiate antibiotic therapy

YES (see below for prescription)NO (patient to visit clinic)Other: _________________________
Please write prescription if desired:
Supportive Care Recommended by Pharmacist

Fluids (water, Gatorade, Pedialyte, etc)Tylenol 325mg (1 - 2 tablets every 4-6 hours), Ibuprofen 200mg (1 tablet every 4-6 hours), Naproxen 220mg (1 tablet every 12 hours)Warm saltwater gargleThroat lozenge/cough cropOther: _______________________________
Pharmacist Follow-Up within 48 hours

Date:_________________ Pharmacist: ______________
Should be Empty:

Group A Strep Test Screening Form

Medicare Part B Information

Colorado Medicaid Information

Insurance Card Information

Current Symptoms

Consent to Testing

Pharmacy Use Only

Pharmacotherapy Plan