COVID-19 BINAXNOW SCREENING FORM: PROSPERITY HEALTH PHARMACY
Name
*
First Name
Last Name
Date of Birth
*
Example: 05/21/1974
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Reason for Test
Are you experiencing any of the following symptoms? Check all that apply:
Fever (at or greater than 100 degrees Fahrenheit)
Chills
Cough
Shortness of breath or difficulty breathing
Fatigue
Muscle or body aches
Headache
New loss of taste or smell
Sore throat
Congestion or runny nose
Nausea or vomiting
Diarrhea
In the past two weeks, did you care for or been deemed a close contact of someone diagnosed with COVID-19?
*
Yes
No
Have you or anyone in your household traveled in the U.S. in the past 21 days?
*
Yes
No
Have you or anyone in your household traveled on a cruise ship in the last 21 days?
*
Yes
No
Are you or anyone in your household a health care provider or emergency responder?
*
Yes
No
By signing this form, I hereby consent and state my preference to have Prosperity Health Pharmacy and its staff to report my test results to the North Dakota Department of Health.
I agree to pay the $90 fee that will be assessed for my appointment. I understand that this fee does not cover the test itself which is provided for free by the State of North Dakota but is assessed in consideration of time, costs and risks undertaken by the pharmacy offering this service.
Printed Name
*
Date
*
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Month
-
Day
Year
Date
Signature
*
Submit
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