Coronavirus testing form

Coronavirus testing form

Needs to be completed by all persons BEFORE coming to get tested. Must complete from (link attached in confirmation e-mail) for us to perform test. When you arrive, please text 240-608-5424 with your name, DOB and time of appt. Do not enter pharmacy until you hear back from us with instructions.
First Name*
Last Name*
Middle Initial
Date of Birth*

MonthDayYear
Date
Phone*
Address*

Address

Street Address Line 2

CityState

Zip
Gender at Birth*
Allergies
Emergency Contact Name & Phone #
Primary Doctor
Dr. Address, City, St
Dr. Phone #
Race*

WhiteAsianBlack or African AmericanAmerican Indian or Alaska NativeNative Hawaiian or Pacific IslanderOtherUnknown
Ethnicity*

Hispanic or LatinoNot hispanic or LatinoPrefer not to answer
Email to Communicate*
example@example.com
Re-enter Email to Communicate*
example@example.com
Type of test being performed (Must match your selection at the time of booking)*
Confirm date of your appointment (Must match your selection from booking)*

MonthDayYear
Pharmacy closed on ALL major holidays. This date should match what you booked
Confirm appointment time Paid already (Must match booking)*

Hour Minutes

AM/PM Option
Name of person whose card/paypal used for payment*

First NameLast Name
Passport #, Country of issue, Date of expiration for Travel tests (If entering # below, bring original passport, photo or copies not accepted)
Type only if required by destination of travel. Remember to bring original during test if you enter #
Check any and all symptoms you may have below (all tests),*

CoughShortness of BreathHeadacheFever, unspecifiedSore throat (Acute)New Loss of tasteNew loss of smellChills, without feverDiarrhea, Nausea or VomittingSuspected Exposure, not inhaledCongestion or runny noseExposure to COVID-19 PatientFatigue, muscle or body achesSuspected exposure, congregate settingNo symptoms or exposure (Screening purpose only)
If you had any symptoms above, when did they start? skip if none*

MonthDayYear
Date
Required SARS CoV2 Survey for all tests (check all that apply):*

This is my first COVID testI am a smokerI have been in an enclosed space with greater than 8 people with no social distancingI am in ICUI have been in contact with someone with COVID-19 in past 14 daysI have traveled out of state or country in last 14 daysI have been advised to get COVID-19 test prior to medical procedureI am currently hospitalizedI have tested positive for COVID antigen test in pastI have tested positive for COVID antibody test in pastI reside in a congregate care facilityI am employed in healthcare settingI am pregnantNone apply
For Antibody tests only (click only those that apply)*

Have you been diagnosed as positive fo COVID -19 with a swab test in past 10 days?Have you had a close contact with someone who has COVID-19 in the past 14 days?Have you been feeling feverish or had a fever higher than 100.5 F in past 3 days?
Consents*

I hereby grant permission to Hillcrest Pharmacy & Compounding, its subsidiaries and affiliates, and each of their agents, employees, officers, directors, servants, successors, heirs, executors, and administrators, (collectively, "HPC") to perform certain screening tests as set forth below at my direction, which may include obtaining specimens of mucus by nasal, nasopharangeal or oropharangeal swab or blood by venipuncture or finger stick. I authorize HPC to obtain these screening results and provide them to me via phone, email or mail. I agree to pay for the tests in full at the time of service. I understand that the testing has not been ordered by a physician and is being done for my own use and not for medical diagnostic or treatment purposes.I understand that the test results will not be forwarded to any medical professional for diagnosis of any medical condition. It is my responsibility to share the test results with my physician at my sole option. I, alone, am responsible for obtaining medical information, treatment or services from a doctor or other health care provider in relation to test results. I authorize HPC to report the administration of this test to the state per regulations. I understand the state may use my information and contact me for any purpose deemed necessary. I understand these tests have not been cleared or approved by the FDA and all these tests have been authorized by FDA under EUA’s for use by authorized laboratories.I understand these tests have not been cleared or approved by the FDA and all these tests have been authorized by FDA under EUA's for use by authorized I have been provided with, read and understood the patient handouts or factsheets for these tests. I understand the risks, limitations, nature of these tests.I understand that PCR test samples may need to be transported/shipped to laboratory for processing. I understand that if the sample is lost, destroyed, damaged during shipping or handling, HPC is only liable to return the fee paid for the test and nothing more.I hereby and for my heirs, executors, administrators, successors and assigns release, acquit and forever discharge HPC, of and from any and all claims, actions, causes of action, demands, rights, damages, injuries and property damage and the consequences thereof resulting or to result from the testing or delay in obtaining results of testing due to shipping or any other reasons. I acknowledge that I have read this release form prior to signing it and that I understand its contents. I understand and agree that I will not be able to sue HPC for any injury or property damage I may suffer as a result of the testing.I HEREBY CERTIFY THAT I HAVE READ THE ABOVE ACKNOWLEDGEMENT AND HAVE HAD AN OPPORTUNITY TO ASK QUESTIONS ABOUT ITS CONTENTS. BY SIGNING BELOW, I CONSENT TO UNDERGO THE SELF-DIRECTED LABORATORY TESTING UNDER THE CONDITIONS SET FORTH HEREIN.
Patient/Guardian Signature*

Clear
Date*

MonthDayYear
Date
Please hit the submit button, without submitting form, we cannot do the test. Print a copy for your records if you like. But please hit submit after completion. You MAY NOT get any confirmation email that you completed this form. Upon successful submission, you will be redirected to our homepage.

Once you arrive, park your car and txt 240-608-5424 with your name, DOB and the type of test you signed up. Please do not enter the pharmacy until you get a txt back with instructions. Lastly, have your ID ready.
Should be Empty: