COVID19 Testing: Patient Form

PATIENT SCREENING FORM

COVID-19 TESTING
IMPORTANT: THIS FORM MUST BE COMPLETED PRIOR TO TESTING for EACH person being tested.
PLEASE READ:

Completing this form is Step 1 of the COVID-19 testing process. Upon completion, you will receive a link via e-mail to book your appointment.

PCR Rapid testing is $95

Antigen Rapid Testing is $50

You must submit separate forms for EACH individual person to be tested including children and dependents.

If you have any questions, please contact us at 305-982-8727 or at info@ethoswellnesspharmacy.com.
What type of test are you requesting?*

PCR TestAntigen Rapid Test
Which test do you need?

PCR Swab Test: To test whether patient is actively infected. This is the test you will likely need for travel documentation.

Antigen Rapid Testing: To test for active infection if currently experiencing symptoms. Nasal swab, results in 20 minutes.
PATIENT NAME*

First NameMiddle NameLast Name
If testing for TRAVEL documentation, the name on this form MUST MATCH PATIENT'S NAME EXACTLY AS WRITTEN IN THEIR PASSPORT. We will not be able to change it afterward.*

I understand the aboveN/A: I am not travelling
GUARDIAN NAME (if patient under 18)

First NameLast Name
PHONE*
Phone Number
E-MAIL (where results will be sent)*
example@example.com
ADDRESS*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
PATIENT DATE OF BIRTH*

MonthDayYear
PATIENT BIOLOGICAL SEX

FemaleMaleOther
If travelling, provide your passport number to include on your result certificate:
Triple check! We cannot change this later.
PATIENT PRIMARY CARE DOCTOR
Primary Physician Name
PRIMARY CARE DOCTOR'S PHONE
Doctor's Phone Number
Does patient have any of the following conditions? (select all that apply)*

Hypertension / High Blood PressureDiabetesCOPD or other lung/respiratory conditionHeart failure / Cardiovascular issuesKidney DiseaseNone of the above conditions
Do you suspect you (patient) may have COVID-19 right now?

Yes, I am currently experiencing symptomsNo, I don't think so

Has patient experienced any of the following symptoms?*

	Yes, within the last 14 days	Yes, within the last 3 days	Currently experiencing this symptom	No, I have not had this symptom
Fever
Cough
Body Ache / Joint or Muscle Pain
Shortness of breath
Loss of smell or taste
Chest pain or discomfort
Vomit or diarrhea
Sore Throat
Fatigue
Chills

In the last 14 days has the patient...*

	Yes	No	If yes, provide date
been diagnosed with COVID-19?
been within proximity of someone who has received a confirmed diagnosis of COVID-19?
been within proximity of someone who was/is symptomatic but undiagnosed?
attended an event with more than 10 people?

Any additional comments you wish to share with the pharmacist:
Notes
I understand that testing will be done by appointment only.

I understand that the Pharmacist will screen each patient to determine testing needs and retains the right to refer patient to another testing facility or healthcare provider.

I understand that I am fully responsible for determining travel requirements.

I understand that results will be sent via e-mail to the e-mail address provided in this form.
I have read and agree to the terms above.*

Yes
Should be Empty:

PATIENT SCREENING FORM