WHITING PHARMACY COVID-19 RAPID TEST

200 Lacey Rd, Whiting NJ, 08759 (732)-929-6330

Rapid COVID Antigen Test Appointment and Consent Form

PLEASE STAY IN THE CAR AND CALL UPON ARRIVIAL

Rapid COVID-19 Test with results within 15 minutes for only $50

Please call to cancel an appointment so that we can make the appointment available for others
Select a time slot for your Rapid COVID-19 Testing Appointment:*
Section 2: Patient Information
Name*

First NameLast Name
Date of Birth (MM/DD/YYYY)*
Phone Number*

Area CodePhone Number
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Yes
MaleFemaleOther
WhiteAmerican Indian or Alaska NativeAsianBlack or African AmericanNative Hawaiian or other Pacific IslanderUnknown
Hispanic or LatinoNot Hispanic or LatinoUnknown
Fever or chillsCoughShortness of breath or difficulty breathingFatigueMuscle or body achesHeadacheLoss of taste or smellSore throatCongestion or runny noseNausea or vomitingDiarrheaPersistent pain or pressure in the chestNone of the above
I have had close contact (within 6 feet of an infected person for at least 15 minutes in a 24 hour period) with someone confirmed with COVID-19. It is recommended to wait at least 5-7 days after exposure for testing.I have traveled to a high-risk locationI have been asked or referred to get testing by a healthcare provider or local or state health departmentI agree to terms & conditions of Whiting Pharmacy. I acknowledge Whiting Pharmacy Notice of Privacy Practices, testing practices & financial disclosures.*
What car will you be arriving in? (Color, Make, Model)*
Section 4: Consent
SERVICE INFORMATION

The test used is an FDA Approved COVID-19 Rapid Antigen test which is a nasopharyngeal swab that is inserted 2-3" into the nostril until resistance is felt. We analyze the results onsite and report back to you in about 15 minutes.

I hereby authorize the pharmacist or nurse from Whiting Pharmacy to perform a COVID-19 Test. I authorize the pharmacist to maintain a copy of this signed form and submit all information to local health departments as required following all HIPPA regulations. I indemnify the organizing body and all persons connected with them from any and all claims that may result from my voluntary participation in the tests.

IMPORTANT INFORMATION

STAY IN YOUR CAR AND PLEASE CALL 732-929-6330 WHEN YOU ARRIVE TO NOTIFY STAFF AND CONFIRM PAYMENT AUTHORIZATION.
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