Laboratory Rapid Tests
This form is to be filled out by those requesting to receive one of the Rapid tests outlined below. You will be contacted with results by the method you request.
Name
*
First Name
Middle Name
Last Name
Birth Date
*
-
Month
-
Day
Year
Date
Gender
Female
Male
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Back
Next
Selected test(s):
*
prev
next
( X )
Streptococcus (Strep)
Time to results: 10 minutes
$
25
Influenza (Flu)
Time to results: 20 minutes
$
25
COVID Antigen
Time to results: 20 minutes
$
25
COVID & Flu Antigen Combo
Time to results: 20 minutes
$
45
Credit Card
I am or above named minor is...
*
Under 3 years of age
3 years of age or older
I am or above named minor is...
*
Pregnant
Not pregnant
I am or above named minor is...
*
Immunocompromised
Not immunocompromised
Symptoms include... (check all that apply)
*
Sudden onset of sore throat
Fever over 100.4
Headache
Nausea/vomiting/abdominal pain
Cough
The following test will be performed:
*
Streptococcus (Strep)
The following test will be performed:
*
Influenza (Flu)
The following test will be performed:
*
Respiratory Syncytial Virus( RSV)
The following test will be performed:
*
Mononucleosis (Mono)
The following test will be performed:
*
COVID Antigen
The following test will be performed:
*
COVID PCR
How would you like your results delivered? (check all that apply)
*
Phone call
Email
I'll wait for a paper copy
Consent for person receiving testing:
*
I understand that, as with any medical test, there is the potential for false positive or negative test results to occur. I understand if I have any unusual symptoms after testing, it is my responsibility to seek medical attention. If I have a positive test results and choose to utilize the Physician360 virtual visit option, I authorized the release of my test results from Tomahawk Pharmacy to Physician360. I, the undersigned, have been informed about the test purpose, procedure, benefits, and risks. I have been given the opportunity to ask questions before I sign, and I have been told that I can ask questions at any time. I voluntarily agree to be tested for the above chosen test(s).
Signature
*
Submit
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