SHP Linden NJ Form

1

2

Select type of COVID-19 Test at Super Health Pharmacy Linden NJ * This field is required.Testing Starts At 10AM Daily!

Covid PCR Test Nasal Swab (Results within 2-3 business days) FREE* (Appointment required)

Rapid Covid Test Nasal Swab (Results within 15 minutes) $115 (No appointment required) Super Health Pharmacy Linden NJ

Rapid COVID-19 PCR Nasal Swab Test $175 (Results within in 15 minutes) Recommended for Travel, Medical Procedures, etc

3

Appointment For COVID PCR Test (Result by 4-5 business days)* This field is required.For multiple family members, please only select one appointment! (Only 1 appointment needed per family/group)

4

Due to High Testing Demand, We do not allow appointment cancellations. Please verify with your end user if they will accept a COVID-19 Test as clearance, if this test is intended for such purpose. (i.e. work, travel, nursing home, hospital, etc.). By Submitting yes, you agree to our terms that Super Health Pharmacy will not be held responsible for any representations.* This field is required.

YESNO

5

Pharmacy Phone For your reference

6

Patient Name* This field is required.

First Name

Last Name

7

Middle Initial

8

Date of Birth* This field is required.MM-DD-YYYY

9

Patient Address * This field is required.

10

City* This field is required.

11

State* This field is required.

12

ZIP Code* This field is required.

13

Race** This field is required.Required By CDC

14

Ethnicity** This field is required.Required By CDC

15

Cell Phone* This field is required.

16

Insured's Name

17

Relationship to Patient

18

Gender* This field is required.

19

Primary InsuranceName of Insurance Company

20

Group #

21

ID#

22

COVID 19 (SARS CoV 2 Assay) via Nasal Swab* This field is required.

COVID 19 (SARS CoV 2 Assay) via Nasal Swab

23

ICD-10 Code* This field is required.

Z20.828 Contact with and suspected exposure to other viral communicable disease

Z11.59 Asymptomatic, no known exposure, results unknown or negative

24

Email *

example@example.com

25

Picture of Government Issued IDDrivers License, Passport, Etc

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

26

Picture of Insurance Card

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

27