COVID/Flu Rapid Result Test
These are rapid antigen tests and results are available within 15 minutes.
Appointment
Name
*
First MI Last
DOB
*
MM/DD/YYYY
Gender
*
Please Select
Male
Female
Gender at birth
Address
*
Street Address, City, State, Zip Code
Phone
*
County
*
Required for LCAHD
PCP
*
Primary Care Provider
Symptoms
*
Fever or chills
New loss of taste or smell
Cough
Sore Throat
Shortness of Breath
Congestion or runny nose
Difficulty Breathing
Nausea or Vomiting
Fatigue
Diarrhea
Muscle or body aches
Asymptomatic
Headache
By submitting this form, I consent to the nasal swab collection of a sample for COVID-19 testing, releasing Eastridge-Phelps Pharmacy of any liability therewith.
Signature
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