Grand Care Pharmacy COVID-19 Form: APPOINTMENTS

1
Select type of COVID-19 Test* This field is required.Testing Starts At 10AM Daily!
Covid-19 Test Nasal Swab (Results within 3 days) FREE (appointment required)
Rapid Covid-19 Antigen Nasal Swab Test (Results within 15 minutes) $125 (Appointment required)
2
Appointment (Call pharmacy for availability)Please call the pharmacy for any last minute openings. Thank You
3
Appointment (Result by 3 business days)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 RAPID 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 Grand Care Pharmacy will not be held responsible for any representations.* This field is required.
YESNO
5
Date of Test* This field is required.Testing Starts At 10AM Daily! You must have an appointment TIME slot booked on previous screen unless otherwise authorized by pharmacy personnel.
Date
Month
Day
Year
6
Pharmacy Phone For your reference
7
Patient Name* This field is required.
First Name
Last Name
8
Middle Initial
9
Date of Birth* This field is required.MM-DD-YYYY
10
Patient Address * This field is required.
11
City* This field is required.
12
State* This field is required.
13
ZIP Code* This field is required.
14
Race** This field is required.Required By CDC
15
Ethnicity** This field is required.Required By CDC
16
Cell Phone* This field is required.
17
Insured's Name
18
Relationship to Patient
19
Gender* This field is required.
20
Primary InsuranceName of Insurance Company
21
Group #
22
ID#
23
COVID 19 (SARS CoV 2 Assay) via Nasal Swab* This field is required.
COVID 19 (SARS CoV 2 Assay) via Nasal Swab
24
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
Z20.818 Suspected Exposure to Covid-19
25
Email *Needed if you need the results emailed to you
example@example.com
26
Picture of Government Issued IDDrivers License, Passport, Etc
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
27
Picture of Insurance Card
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
28
Secure Payment Portal* This field is required.Payment is nonrefundable; We will provide an itemized receipt if you would like to submit this to your insurance for possible reimbursement.
prevnext( X )
My Bag
1
My Bag
Great Product Name
$20
Quantity:1
Size:Small
RemoveEdit
Great Product Name
$20
Quantity:1
Size:Small
RemoveEdit
Great Product Name
$20
Quantity:1
Size:Small
RemoveEdit
Great Product Name
$20
Quantity:1
Size:Small
RemoveEdit
ORDER SUMMARY
Total costUSD
Rapid COVID-19 TESTFastest way to get in and out is by paying online
$120.00+
Back
Rapid Antigen Test
Rapid Antigen Test
Rapid PCR Test
Pay In Person
Rapid COVID-19 Test
Subtotal: $0.00
Total cost $0.00
Credit Card (If paying IN person, simply click submit) Paying Online is the fastest method!
First Name
Last Name
Credit Card Number
Security Code
Expiration Date
Postal Code
29
COVID-19 Rapid Test Result
PositiveNegative
30
Type of Test
BD VERITOR Analyzer System
ACCESS BIO CareStart System
31
Tags
[object Object]
Should be Empty:

Save your progress

Save your progress

Your form submission has been saved as a draft.

Save your progress

Your form submission has been saved as a draft.