Strep Test Patient Screening Form

Patient Screening and Consent Form Streptococcal Pharyngitis (Strep Test)

** TESTING IS ONLY AVAILABLE AT OUR BLUFF STREET LOCATION **
Please fill out the form below in its entirety, sign and submit. You will receive a green checkmark upon a successful submission. If you have any questions, please call us at 435-674-5667.

The cost of the screen is $35. Insurance does not cover the cost. The test is HSA/FSA eligible. Those cards may be entered for payment. (There is a $15 after hours fee for special requests.)

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 antibiotic can be prescribed on-site for an additional charge.
Appointment*
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Primary Care Physician Name* .
Patient Symptoms-Check all that apply*

Sudden onset of sore throatFever >101.5HeadacheNausea/vomitingSwollen/red/patchy tonsils

Payment*

Rapid Strep TestThis throat swab test determines if a person has been infected with Group A beta-hemolytic strep.

$35.00

After Hours FeeOn call fee for after regular store hour test.

$15.00

Total

$0.00

By signing below:
A. I authorize Brent’s Pharmacy to conduct collection and testing for Strep A.
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 Strep A 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, 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 Strep A.
Signature*

Clear
If patient is under 18 years old, representative name Name* . What is the representatives relationship to the patient? Relation*
Should be Empty:

Patient Screening and Consent Form Streptococcal Pharyngitis (Strep Test)