COVID-19 Testing intake form

Rapid COVID-19 Antigen Test

This rapid antigen test is a nasal swab test to see if a person has a current COVID-19 infection. This type of test may be particularly useful if a person has exposure to someone who is suspected to be covid-19 positive. the test being offered is the BD Veritor Plus System for rapid detection of Covid-19 (SARS-CoV-2). Results from the rapid test will be available same day. Testing is available by appointment only. Testing times are available on Monday, Tuesday and Wednesdays, with available times posted on the booking page. Individuals should remain in the vehicle and a healthcare professional in personal protective equipment will come to your vehicle to collect the sample. Patients will be called with their results within 4 hours of their testing time. It is important that individuals who are symptomatic or who are close contacts of a positive case continue to quarantine until you receive test results. If your test is positive, you will receive a call from public health with further instructions. Please note if you have previously been told to quarantine for 14 days because you are close contact, you will need to continue that entire quarantine period, even if you test results are negative.

Cost for testing is $99.99

We can provide you a receipt if you choose to send to your insurance.

Payment is accepted by bank card only. We will take payment information prior to testing. HSA cards will be accepted. If you have a problem processing payment on your HSA Card, please give us a call at 360-503-7761

Name *

First Name Last Name

E-mail *

example@example.com

Phone Number *

Area Code Phone Number

Birth Date

Month Day Year

Have you had direct contact with someone who is confirmed to have COVID-19? *

No Yes

Do you have a new onset of cough? *

No Yes

Do you have shortness of breath? *

No Yes

Do you have a sore throat? *

No Yes

Do you have a fever of 100 or greater? *

No Yes

Do you have new onset of muscle ache? *

No Yes

Have you recently lost the ability to taste of smell? *

No Yes

Have you been tested for COVID-19 in the last 30 days? *

No Yes

Credit Card
First Name	Last Name
Credit Card Number	Security Code
Expiration Month	Expiration Year
Billing Address
Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Covid 19 Test line: 360-503-7761

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