Influenza Testing Consent Form

Patient Screening and Consent Form Influenza A&B (flu test)

** THIS TEST IS ONLY ADMINISTERED AT OUR BLUFF STREET LOCATION **
Please fill out the form below in its entirety, sign and submit. You will see a green check mark if the submission is successful. If you have any questions, please call us at 435-674-5667.

The cost of the screen is $45. Insurance does not cover the cost. The test is HSA/FSA eligible, you may enter those cards for payment.

We can NOT test anyone under the age of 3 years old, pregnant women or patients who are immuno-comprimised (HIV, cancer treatments, etc).

Results will be completed within 10 minutes of testing.

If the test is positive, an antiviral can be prescribed on site for an additional charge.
Appointment*
Today's Date

MonthDayYear
Date
Name

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth*

MonthDayYear
Date
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Do you have any of the following medical conditions?*

DiabetesObesityModerate/Severe AsthmaSerious Heart ConditionKidney Disease/DialysisLiver DiseaseCOPDCancer TreatmentCorticosteroid TreatmentBone Marrow/Organ TransplantHemoglobin DisorderImmune DysfunctionHIVSmokingPregnant
Who is your Primary Care Physician?
Are you currently experiencing any of these symptoms? (Check all that apply)*

FeverChillsShortness of breathFatigueMuscle pains or body achesHeadachesNew loss of taste or smellSore throat
How long have you had these symptoms? *
Payment Information
Is payment for the test self pay or billed to a business/corporation account?

Self payBusiness/corporate account

Please select the test you would like and enter credit/debit card info below. *

BD Veritor Flu (A+B) TestRapid test for seasonal flu (strains A+B). Results in 15 minutes.

$45.00

Total

$0.00

Credit Card

Authorization/Consent
By signing below:
A. I authorize Brent’s Pharmacy to conduct collection and testing for Influenza A&B.
B. I understand, as required by law, my test results may be disclosed to the county, state, or to other governmental entity.
C. I understand Brent’s Pharmacy is not acting as my medical provider, this testing does not replace treatment by my medical provider, and I assume complete and full responsibility to take appropriate action with regards to my test results. I agree to seek medical advice, care, and treatment from my medical provider if I have questions or concerns, or if my condition worsens.
D. I understand that, as with any medical test, there is the potential for a false positive or false negative Flu test result. I, the undersigned have been informed about the test purpose, procedures, possible benefits, and risks. I have been given the opportunity to ask questions before I sign, and I have been told that I can ask additional questions at any time and will receive a copy of this informed consent upon request. I voluntarily agree to this rapid antigen test for Influzenza A&B.
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Patient Screening and Consent Form Influenza A&B (flu test)

Payment Information

Credit Card

Authorization/Consent