Covid 19 Testing Appointment and Consent Form

Rapid COVID-19 Testing

Appointment and Consent Form
Appointment *
The cost of the test is $99.00

Family Care Pharmacy does not accept insurance for the test.
Name *

First Name Last Name
Birth Day *

Month Day Year
Last 4 Digits of Social Security Number
Gender *

Female Male Other
Cell Phone Number *

Area Code Phone Number
Email
example@example.com
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Race *

African American or Black American Indian or Alaska Native Asian Native Hawaiian or Other Pacific Islander White Other Do Not Wish to Answer
Ethnicity

Hispanic or Latino Not Hispanic or Latino Do Not Wish to Answer
Is there a chance you may be pregnant? *

Yes No Unknown
Is this your first test? *

Yes No Unknown
Are you symptomatic? *

Yes No Unknown
When did your symptoms begin?

Month Day Year
Date
Check all symptoms you have experienced that might be associated with COVID-19*. *

None Fever Cough Shortness of Breath/Difficulty Breathing Sore Throat Runny Nose Congestion Headache Sweats Chills Diarrhea Vomiting Weakness Fatigue Muscle aches Loss of taste Loss of smell Altered mental status
Please describe any other symptoms not listed above
Are you employed in a healthcare setting? *

Yes No Unknown
Do you live in a congregate care setting? *

Yes No Unknown
What type of congregate care setting do you live in?

Assisted Living Home Nursing Home Retirement home Substance Abuse treatment center Sheltered housing Prison based care site Boarding house Hospice Religious institutional residence

By signing this form, I agree to the following:

a. I authorize this COVID-19 testing unit to conduct collection and testing for COVID-19 through a nasopharyngeal swab (a swab in the nose) or an oral swab (a swab in the throat).

b. I authorize my test results to be disclosed to the Florida Covid19 Reporting Portal.

c. I acknowledge that a positive test result is an indication that I should self-isolate and wear a mask or face covering as directed.

d. I understand the Family Care Pharmacy is not acting as my c medical provider, this testing does not replace treatment by my medical provider, and I assume complete and full responsibility to take appropriate action when I receive my test results. I agree I will seek medical advice, care and treatment from my medical provider if I have questions or concerns, or if my condition worsens.

e. I understand that, as with any medical test, there is the potential for a false positive or false negative COVID-19 test result.

f. I understand that there will be a $99.00 charge for this test payable over the phone at 813-659-9777. Calling hours are 9am to 6pm Monday to Friday only.

I, the undersigned, have been informed about the test purpose, procedures, possible benefits and risks, and I have received a copy of this Informed Consent and the Notice of Privacy Practices.
When you arrive for your appointment please park on the West side of our building by our electronic billboard street sign. There are 2 curbside spaces where we will perform your test carside.

Please call us prior to your test at 813-659-9777 to pay via credit card over the phone to secure this appointment.
Signature *

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