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 NameLast Name
Date of Birth*
Address*

Street Address

Street Address Line 2

CityState / Province

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

Black or African AmericanWhiteAsianAmerican Indian or Alaska NativeNative Hawaiian or Other Pacific IslanderUnknownOther
Ethnicity

Not HispanicHispanic

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)