COVID-19 Test Screening & Consent Form

COVID-19 Test Screening & Consent Form

Chicago Healthmart Pharmacy. 1406 W Devon Ave. Chicago, IL 60660 P:773-856-0944
Name *

First Name Last Name
Date of Birth *
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Email *
example@example.com
Phone Number *
Please enter a valid phone number.
Race (Check all that apply)

Black or African American White Asian American Indian or Alaska Native Native Hawaiian or Other Pacific Islander Unknown Other
Ethnicity

Not Hispanic Hispanic

I, the undersigned, have been informed about the test purposes, possible benefits and risks, and I acknowledge that I may request a copy of this informed consent. I understand that I may ask questions at any time and I voluntarily agree to testing for COVID-19.
Consent
Signature *

Clear
Failure to accurately provide all of the requested information will delay your appointment and may cause it to be rescheduled. Please call us with questions BEFORE submitting this form.

Testing Options

PCR Antigen Test (result available in 48 hours) Rapid Antigen Test (result available in 30 minutes)

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