Language
English (US)
Pharmacy Testing Form
500 4th Ave, Brooklyn, NY 11215
Park Chemists Location
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Please Select
500 4th Ave Brooklyn, NY 11215
164 5th Ave Brooklyn, NY 11217
Park Chemists Street
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Please Select
500 4th Ave
164 5th Ave
Park Chemists Zip Code
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Please Select
11215
11217
Park Chemists Phone
*
Please Select
(718) 567-5444
(718) 393-5555
Online Scheduling
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Please Select
Yes
No
Section - Form Body
Testing Options
Select the testing you would like to receive. Rapid test results are within 15 minutes. PCR test results are within 24-48 hours.
What test(s) would you like to receive?
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COVID & Influenza A/B Rapid (2yr+)
RSV Rapid (18yr and under)
Patient Information
Patient Name
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First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date Picker Icon
Date of Birth Formatted
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-
Month
-
Day
Year
Date
Legal Gender
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Please Select
M - Male
F - Female
X - Non-binary
Gender ID
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Please Select
W - Woman/Girl
TW - Transgender Woman/Girl
M - Man/Boy
TM - Transgender Man/Boy
NB - Non-Binary Person
GNC - Gender Non-Conforming
Q - Not Sure/Questioning
NR - Chose not to Respond
GNL - Gender not listed (write-in)
GNL - Write In Gender ID
*
Choose One
*
Pregnant
Postpartum
Neither
Ethnicity
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Please Select
DECL - Declined
HIS - Hispanic Origin
NHL - Non-Hispanic Origin
UNK - Unknown
Race
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Please Select
AIA - Native American or Alaskan
ASN - Asian
BAA - African American or Black
DECL - Declined
NHP - Native Hawaiian or Pacific Islander
WHT - White
OTH - Other or Multiracial
Address
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Street Address
Street Address Line 2
City
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Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
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Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
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Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Phone
*
10-digital phone number
Email
*
example@example.com
Patient Questions
Have you been in contact with someone with COVID-19 in the past 14 days?
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Yes
No
Possibly
Do you currently work in a healthcare setting with direct patient contact?
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Yes
No
Do you currently have one or more of the following symptoms?
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Fever or chills
Cough
Shortness of breath or difficulty breathing
Fatigue
Muscle or body aches
Headache
New loss of taste or smell
Sore throat
Congestion or runny nose
Nausea or vomiting
Diarrhea
None of the above
If Yes, when did your symptoms start?
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Month
-
Day
Year
Date
Do you currently reside in a congregate (group) care setting?
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Yes
No
Occupation
*
Employer Name
*
Employer Address
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Employer Phone Number
Please enter a valid phone number.
Are you a student or a volunteer at a school?
*
Yes
No
If Yes, What is the name of your School?
Have you had a covid-19 test Recently?
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Yes
No
Do You have Insurance?
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Yes
No
Front of Insurance Card
*
Upload File
Drag and drop files here
Choose a file
Cancel
of
Back of Insurance Card
*
Upload File
Drag and drop files here
Choose a file
Cancel
of
I Authorize Park Chemists to Bill My Insurance For This Test
*
Yes
Out Of Pocket Prices
Section - Form Consent
Consent
I acknowledge that all information I entered in this form is accurate and true.
I authorize this facility to collect a sample specimen for me in order to perform this test.
I release the facility and all of its employees and affiliates, from any liabilities, damage, or accidents related to this testing activity.
I authorize this facility to share with the requester (e.g., company) my health care information, including diagnostic test results and medical test results.
I understand that this diagnostic test is for informational purposes only. This facility will not admit patients or provide medical advice.
I acknowledge and give consent for this test request.
*
Yes
Submission Date
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Month
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Day
Year
Date
Please verify that you are human
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Signature
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