Influenza Testing Consent Form

Patient Screening and Consent Form Covid & 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 FLU test is positive, a flu 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 Covid & Influenza A&B (flu test)

Payment Information

Credit Card

Authorization/Consent