COVID-19 Rapid ANTIBODY Test

COVID-19 Rapid ANTIBODY Test

If you want to find out if you currently have COVID, please exit this form and request an ANTIGEN test. If want to find out if you have previously had COVID, please complete the form below.
Full Name*
Address*

Street Address

Street Address Line 2

CityState

Zip Code
County*
Cell Phone
E-mail Address*
example@example.com
Date of Birth*

MonthDayYear
Gender*
Do you have any allergies? If so, please list.
Ethnicity*
What medical conditions do you have?
Name of your pharmacy:
Are you currently pregnant?

YesNoNot Applicable
Are you currently experiencing severe symptoms such as shortness of breath, continuous pain or pressure in the chest, or persistent fever greater than 102 degrees?

YesNo
Do you have reason to believe you have recently been in contact with the SARS-CoV-2 virus? If so, briefly explain:
This test is intended to expand access to COVID-19 risk screening. This test does NOT diagnose infection. It is not intended for people experiencing symptoms or who may need more immediate medical care. Please visit the CDC website for information on what to do if you are sick.

By submitting below, I understand and agree that:
1. I have asked to receive the COVID-19 antibody test and that I am age 18 or over.
2. The above test is a qualitative test that detects the presence of antibodies to the SARS-CoV-2 virus. It is not being done for diagnostic or treatment purposes. Results from antibody testing should not be used as the sole basis to diagnose or exclude SARS-CoV-2 infection or to inform infection status.
3. The pharmacist's consultation with me about the test results does not constitute medical advice.
4. The data derived from the test is considered preliminary and is not conclusive as to the absence or presence of any disease or health condition.
5. Sumpter Pharmacy recommends that I report the results of the test to my healthcare professional so she or he can help me determine whether I need followup care.
6. The responsibility for seeking followup medical advice regarding the test result is mine and not that of any organization or professional associated with the test.
7. I understand that Sumpter Pharmacy will not submit a claim to any insurer for the test given to me. The cost of the testing is my personal responsibility and must be paid prior to testing.
8. I understand Sumpter Pharmacy is bound by HIPAA to protect my privacy, but that results may be shared with providers, public health officials, and authorities such as state and federal government agencies as appropriate for study of the current worldwide pandemic.
9. In consideration for undergoing the test, I hereby release and hold harmless Sumpter Pharmacy and their respective owners, directors, officers, and employees from any liability arising from the testing.
10. By signing this Electronic Signature Acknowledgment Form, I agree that my electronic signature is the legally binding equivalent to my handwritten signature and that it has the same validity and meaning as my handwritten signature.
Patient e-Signature (use your cursor to sign)*

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Today's Date

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Date
Approximate Day/Time You Plan on Testing?
Walk-ins welcome M-F 9:30a-5:30p or Sat 10a-12p
Should be Empty: