AstisRx COVID-19 Test Request

Asti's Pharmacy COVID Test Request Form

Please complete the form below to request and schedule your test. IMPORTANT: When you arrive to the pharmacy for your appointment for rapid antigen testing, please REMAIN in your vehicle and call the pharmacy at 412-512-4850 and one of our team members will come service you curbside. THANK YOU
Patient Name

First NameLast Name
Patient Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Patient Date of Birth

MonthDayYear
Age
BE ADVISED

Children under the age of 15 are only eligible for a Rapid PCR Test (limited availability).

Rapid Antigen Tests have a minimum age of 15 years old.
Email
example@example.com
Gender
Primary Care Physician
Are you a current prescription customer at Asti's Pharmacy?
List Your Medication Allergies (if no allergies, type "n/a")
Current Medications
Please Select Any of the Following that are TRUE:
Other Relevant Medical History
Why are you requesting a COVID Test?
When did your symptoms start for your current illness?

MonthDayYear
Date symptoms began?
Which of the following symptoms are you currently experiencing? (select all that apply)

Other
What was/is your temperature?
What other symptoms are you experiencing?
Have you taken any medications for these symptoms?
What medication(s) have you taken?
Did you receive the Flu Vaccine this year?

COVID-19 ANTIBODY Test

This is a finger-prick blood test to test for the presence of ANTIBODIES for SARSCoV2 (COVID-19) virus. This will NOT test for active infection.

$50.00

COVID-19 Rapid ANTIGEN Test

This a nasal-swab test to check for ACTIVE INFECTION of COVID-19.

$75.00

COVID-19 Rapid PCR Test

This is a nasal PCR test with results within 30 minutes. This test meets Travel Testing Requirements.

$165.00

Printed Test Result

If you would like to have a signed document attesting your results.

$10.00

Enter coupon

Total

Asti's Pharmacy COVID Test Request Form