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First Name
Last Name
Date of birth
Phone Number
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Area Code
Phone Number
E-mail address
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Height
for Children
Weight
for Children
Drug allergies
Do you see a Primary Care Physician?
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Yes
No
If yes, please list name of physician.
When did the symptoms begin?
Symptoms
Body aches
Diarrhea
Fever greater than 100.4 F
Nausea
Sore Throat
Stuffy Nose
Tiredness
Vomiting
Cough
List any conditions below that you being currently treated for:
Have you received a flu vaccine?
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-- Please Select --
Yes
No
If yes, when was the last vaccination?
Did you take something like Tylenol (acetaminophen), Aleve (naproxen), or Motrin/Advil (ibuprofen) before you came to the clinic?
Please Select
-- Please Select --
Yes
No
If yes, what did you take (type/amount)?
If yes, when did you last take the medication?
Enter name for consent:
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Rapid Strep Test
$
35.00
15 minute testing result for Group A Streptococcal Pharyngitis
Rapid Flu A, Flu B, COVID Combo Test
$
65.00
15 minute test results for all 3 in 1 test (Flu A, Flu B, & COVID)
Rapid PCR Covid Test
$
100.00
15 minute PCR lab testing
Quantity
1
2
3
4
5
6
7
8
9
10
Rapid Flu A+B Antigen Test
$
35.00
15 minute rapid antigen test
Quantity
1
2
3
4
5
6
7
8
9
10
Total
$
0.00
Credit Card
Submit Form
Office Use Only
Value
Temperature
Blood Pressure
Pulse Ox
Tonsillopharyngeal inflammation
Patchy tonsillopharyngeal exudates
Palatal petechiae
Anterior cervical adenitis
Office Use Only
Result
Flu A
Flu B
SARS COVID
Strep A
Should be Empty: