Wagner College-Super Health Pharmacy COVID-19 Form

1
Image Field
2
Select type of COVID-19 Test* This field is required.You will also have the option to do the free test with the rapid test at the end of the form.
Covid-19 PCR Nasal Swab Test via Lab (Results within 2 days) Zero out of pocket cost
3
Appointment
4
Appointment (Result by 2 business days)New 2 Minute Intervals. One appointment per person.
5
Due to High Testing Demand, We do not allow appointment cancellations. Please verify with your end user if they will accept a RAPID COVID-19 Test as clearance, if this test is intended for such purpose. (i.e. work, travel, nursing home, hospital, etc.). By Submitting yes, you agree to our terms that Super Health Pharmacy will not be held responsible for any representations.* This field is required.
YESNO
6
Pharmacy PhoneFor your reference
7
Patient Name* This field is required.
First Name
Last Name
8
Middle Initial
9
Date of Birth* This field is required.MM/DD/YYYY
Please make sure your birthday is in this format (MM/DD/YYYY) otherwise your registration might be rejected (ex. 12/01/1999)
10
Patient Address * This field is required.
11
City* This field is required.
12
State* This field is required.
13
ZIP Code* This field is required.
14
Race** This field is required.Required By CDC
15
Ethnicity** This field is required.Required By CDC
16
Cell Phone* This field is required.
17
Insured's Name
18
Relationship to Patient
19
Gender* This field is required.
MaleFemale
20
Are you Pregnant/Postpartum?
YESNO
21
Primary InsuranceName of Insurance Company
22
Group #
23
ID#
24
COVID 19 (SARS CoV 2 Assay) via Nasal Swab* This field is required.
COVID 19 (SARS CoV 2 Assay) via Nasal Swab
25
ICD-10 Code* This field is required.
Z20.828 Contact with and suspected exposure to other viral communicable disease
Z11.59 Asymptomatic, no known exposure, results unknown or negative
26
Email *Very important your email is accurate for testing instructions.
example@example.com
27
Picture of Government Issued IDDrivers License, Passport, Etc
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
28
Picture of Insurance Card
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
29
Secure Payment Portal* This field is required.Payment is nonrefundable; We will provide an itemized receipt if you would like to submit this to your insurance for possible reimbursement. SELECT YOUR OPTION FROM THE DROP DOWN.
prevnext( X )
My Bag
1
My Bag
Great Product Name
$20
Quantity:1
Size:Small
RemoveEdit
Great Product Name
$20
Quantity:1
Size:Small
RemoveEdit
Great Product Name
$20
Quantity:1
Size:Small
RemoveEdit
Great Product Name
$20
Quantity:1
Size:Small
RemoveEdit
ORDER SUMMARY
Total costUSD
Rapid COVID-19 TESTFastest way to get in and out is by paying online
$120.00Edit
Back
Rapid Antigen Test
Rapid Antigen Test
Rapid Antibody Test
Rapid COVID-19 Test
Total cost $0.00
Credit Card (If paying IN person, simply click submit) Paying Online is the fastest method!
First Name
Last Name
30
Would you like to do the Free Test through the Lab as well with your Rapid Test?* This field is required.Results within 2-3 days
YESNO
31
You will now be redirected to siParadigm Lab Portal. You must register with the lab in order to get the Free PCR Test. Results will take 2 days. You may need to use different email addresses for different patients. Please provide the confirmation number you get from the lab via email when you arrive at the testing location on campus. Only fill out the siParadigm portal if this is your first time testing with us on campus, otherwise you can use the same confirmation code used previously.
Should be Empty: