COVID-19 Test Patient Intake Form
Please note that Queens Pharmacy does not accept any insurance for COVID testing. We can provide you with all necessary documents to submit a claim to get reimbursed by your insurance. If you have a FSA or HSA card that can be used to pay for the test.
Appointment Date and Time
*
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Gender
Please Select
Male
Female
Rather Not Say
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Type of test requested
*
Please Select
RT-PCR (99$)
Rapid-Antigen Test (40$)
COVID + FLU Rapid- Antigen test (80$)
All test results are guaranteed within 2 hours.
I authorize a COVID-19 Test as ordered by the authorized healthcare provider. I further understand, agree, certify, and authorize the following: 1. The patient named above is consenting to the mentioned COVID-19 testing. 3. This test has not been Food and Drug cleared or Administration (FDA) approved and has been authorized by FDA under an Emergency Use Authorization (EUA). 4. I understand that this test does NOT rule out COVID-19 in ALL COVID-19 Patients. The possibility of a false negative result should be considered in the context of recent exposures and the presence of clinical signs and symptoms consistent with COVID-19. If COVID-19 is still suspected based on exposure history together with other clinical findings, re-testing should be considered. 5. I understand this test is for COVID-19 screening purposes ONLY. This screening event is NOT for Medical or life-threatening medical emergencies. This screening event is NOT intended for diagnosis, treatment, recommendation and/or management of ANY medical conditions. This screening event is NOT a substitute for a regular Company or Physician visit By signing below I acknowledge that I have read, understand, agree, certify, and/or authorize the information above and further agree to not hold Queens Pharmacy, its employees, agents, and contractors from any and all liability and claims.
*
Submit
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