FREE Rapid STI 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 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 tests for STIs. I understand that the tests being provided to me today are through a grant and do not quantee that there will be no charge for tests in the future. This assessment does not constitue a medical diagnosis. Negative results do not preclude 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 or rapid PCR tests. 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, or are displaying many of the symptoms, you may wish to follow up with a more accurate test at another clinic to confirm the results. 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 STI diagnostic tests. I understand that by signing below I am responsible for following up with another provider if refered onto by the pharmacist.
Pharmacist Follow-Up in 48 hoursDate:_____________________ Pharmacits:___________________________