COVID-19 Antibody Test Form(live) - A & B PHARMACY-With Schedule and Payment

Name*

First NameLast Name

Age

Gender

MaleFemale

Date of Birth

Date

Race/Ethnicity

Address

Street Address

Street Address Line 2

CityState

Zip Code

Patient Phone Number

Email

example@example.com

1) Have you had any of the following symptoms in the last 24 hours?*

	Yes	No
Cough
Shortness of breath of difficulty breathing

OR at least TWO of the following symptoms in the last 24 hours:*

	Yes	No
Fever (usually 100.4 or higher)
Chills
Repeated shaking with chills
Muscle pain
Headache
Sore throat
New loss of taste or smell

If you answered “Yes” to question one, please DO NOT come into work. You should:

Self-quarantine for at least 10 days from the date on which you first experienced any of the above symptoms; AND
Wait until you have had no fever for at least 3 days (without the use of fever-reducing medication) AND
Improved respiratory symptoms (no cough, shortness of breath)

2) In the last 7 days have you:*

	Yes	No
tested positive for Covid-19 by a molecular (PCR) test

3) In the last 10 days have you:*

	Yes	No
Experienced loss of smell or taste
Experienced shortness of breath, weakness or lethargy?
Experienced lightheadedness or dizziness
Experienced vomiting or diarrhea, slurred speech or seizure

4) In the last 14 days have you:*

	Yes	No
Been in contact with someone who was diagnosed with COVID-19?
Been in close contact with someone who had COVID-19 symptoms?
Traveled internationally or taken a cruise

I certify to the best of my knowledge; this information is accurate.

Patient Signature*

Date Signed*

Date

By clicking"Submit", you indicate that you, as the patient or legal guardian of the patient, agree:

to follow up with my regular medical provider for ongoing care;
to the best of my knowledge, all information submitted is accurate;
to the Terms of Service and Consent to Telehealth.
I understand that the total due now does not include any POC fees and that I am responsible for any fees billed by the Pharmacy.

TESTING DATE

Date

COVID-19 Antibody Test Request