Community Pharmacy of Deltona COVID-19 Test Scheduling and Consent Form

COVID-19 Rapid Test Scheduling and Consent Form
Do you currently have any symptoms of COVID-19?

YesNoUnsure
If yes, what symptoms?

FEVERCHILLSCOUGHSHORTNESS OF BREATHDIFFICULTY BREATHINGNEW LOSS OF TASTE OR SMELLCONGESTION OR RUNNY NOSEFATIGUEHEADACHESORE THORATNAUSEA OR VOMITINGDIARRHEA
Have you had close exposure to someone with COVID-19 in the last 10 days?

YesNoUnsure
Have you tested positive for COVID-19 in the last 10 days?

YesNo
Are you travelling and need a test?
First Name*
Last Name*
Date of Birth*

MonthDayYear
Gender*
Ethnicity*

HispanicNon-HispanicUnknown
Race (Check all that apply)*

American Indian or Alaskan NativeAsianBlack or African-AmericanNative Hawaiian or Other Pacific IslanderWhiteUnknownOther
Phone Number:*
Is patient pregnant?*
E-mail*

Confirmation Emailexample@example.com
Home Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
County of Residence *
Appointment*
By providing your consent to take a test for Covid-19 voluntarily, you will be confirming that you understand the following:
- I understand my test results will be disclosed to the county and state health entities as required by law.
- I acknowledge that a positive test result is an indication that I may by required to isolate to avoid infecting others.
- The test requires a nasopharyngeal swab or fingerstick and is not guaranteed to be painless.
- The test takes an average of 15 minutes to return a result.
- Variable results are possible in persons who are immunosuppressed.
- A positive test does not confirm developing immunity to COVID-19.
AT THIS TIME, DUE TO DEMAND AND BILLING MECHANISMS, WE CANNOT BILL MEDICAL INSURANCES DIRECTLY. However, upon request we can provide the necessary paperwork for you to submit to your insurance company manually for reimbursement

My Products*

Covid-19/Flu A&B rapid testCOVID-19/Flu A&B test is designed to detect antigens from SARS-CoV-2, influenza A, and /or influenza B

$99.00

COVID-19 Antigen Rapid POC Test (ACTIVE INFECTION TEST) Product Image

COVID-19 Antigen Rapid POC Test (ACTIVE INFECTION TEST)COVID-19 Antigen Rapid POC Test is a immunochromatographic assay for the detection of extracted nucleocapsid protein antigens specific to SARS-CoV-2 in nasopharyngeal swab specimens directly collected from individuals

$65.00

Covid-19 Antibody IgG/IgM POC TestCOVID-19 IgG/IgM Rapid Test Device is a rapid lateral flow chromatographic immunoassay intended for the qualitative detection and differentiation of IgM and IgG to SARS-CoV-2 in human venous whole blood (sodium EDTA), serum, plasma (sodium EDTA) and fingerstick whole blood.

$50.00

RT-PCR testPCR tests detect viral RNA and remains the gold standard for detecting an active COVID-19 infection. This test is suitable for travel purposes

$199.00

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Total

$0.00

Signature*

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COVID-19 Rapid Test Scheduling and Consent Form