Grand Care Pharmacy COVID-19 Form: APPOINTMENTS

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Grand Care Pharmacy COVID-19 Form

Hi there, please fill out and submit this form.

1
Select type of COVID-19 Test* This field is required.Testing Starts At 10AM Daily!
Covid-19 Test Nasal Swab (Results within 2 days) FREE (Walk-ins Accepted)
Rapid Covid-19 Antigen Nasal Swab Test (Results within 15 minutes) $75 (Walk-ins Accepted)
2
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
3
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
4
Pharmacy Phone For your reference
5
Patient Name* This field is required.
First Name
Last Name
6
Middle Initial
7
Date of Birth* This field is required.MM-DD-YYYY
8
Patient Address * This field is required.
9
City* This field is required.
10
State* This field is required.
11
ZIP Code* This field is required.
12
Race** This field is required.Required By CDC
13
Ethnicity** This field is required.Required By CDC
14
Cell Phone* This field is required.
15
Insured's Name
16
Relationship to Patient
17
Gender* This field is required.
18
Primary InsuranceName of Insurance Company
19
Group #
20
ID#
21
COVID 19 (SARS CoV 2 Assay) via Nasal Swab* This field is required.
COVID 19 (SARS CoV 2 Assay) via Nasal Swab
22
ICD-10 Code* This field is required.
Z20.828 Contact with and suspected exposure to other viral communicable disease
Z20.818 Suspected Exposure to Covid-19
R06.02 Shortness of breath
R05 Cough
23
Email *Needed if you need the results emailed to you
example@example.com
24
Picture of Government Issued IDDrivers License, Passport, Etc
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
25
Picture of Insurance Card
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
26
COVID-19 Rapid Test Result
PositiveNegative
27
Type of Test
BD VERITOR Analyzer System
ACCESS BIO CareStart System
28
Tags
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