COVID-19 RT-PCR Form(live) - A & B PHARMACY-With Schedule and Payment

COVID-19 RT-PCR Form
Appointment Schedule
FAMILY MEMBERS WITH DIFFERENT TIMES CAN VISIT FOR APPOINTMENTS AT THE SAME TIME

WALKINS ARE WELCOME !!!!
Select Your Date and Time*

Patient Demographic Information
Name

First NameLast Name
Age
Gender

MaleFemale
Date of Birth

MonthDayYear
Date
Race/Ethnicity
Address

Street Address

Street Address Line 2

CityState

Zip Code
Patient Phone Number
Please enter a valid phone number.
Email
example@example.com
Job Position/Title
Company Name
Additional Family Members
Patient Health Information
What are the symptoms you're currently experiencing?

FeverLethargic (Tiredness)RestlessnessDry coughBody acheNasal CongestionRunny NoseLoss of SmellDiarrheaLoss of Apetite
Do you have any of the medical condition below:

DiabetesHypertensionCardiac ProblemsImmunocompromisedPregnantChronic Respiratory DiseaseLiver ProblemsKindney ProblemsOther

	Yes	No
In the past 24 hours, have you had a fever?
In the past 7 days, have you had a cough, shortness of breath, or difficulty breathing that's new or getting worse?
In the past 3 days, have you had any of these symptoms: Fever or feeling feverish (chills, sweating), Fatigue (feeling tired all the tire), Muscle or body aches, Headache, New loss of smell or taste, Sore throat, Nausea, vomiting, or diarrhea?
Do you currently have a runny nose or nasal congestion?
In the past 14 days, have you been in contact with someone who you know was diagnosed with COVID-197

In the past 24 hours, have you had a fever?

YesNo
In the past 7 days, have you had a cough, shortness of breath, or difficulty breathing that's new or getting worse?

YesNo
In the past 3 days, have you had any of these symptoms: Fever or feeling feverish (chills, sweating), Fatigue (feeling tired all the tire), Muscle or body aches, Headache,New loss of smell or taste, Sore throat, Nausea, vomiting, or diarrhea?

YesNo
Do you currently have a runny nose or nasal congestion?

YesNo
In the past 14 days, have you been in contact with someone who you know was diagnosed with COVID-197

YesNo
Collection Date

MonthDayYear
Date
Specimen Collected

Nasopharyngeal
If yes, what is the influenza test result?

PositiveNegative
What type of influenza test?

RapidPCR
Have you been tested for COVID-19

YesNo
If yes, what is the COVID-19 test result?

PositiveNegative
What type of COVID-19test?

RapidPCR
Acknowledgment and Consent
- I acknowledge that all information I entered in this form is accurate and true.
- I authorize this facility to collect a sample specimen for me in order to perform this test.
- I release the facility and all of its employees and affiliates, from any liabilities, damage, or accidents related to this testing activity.
- I authorize this facility to share with the requester (e.g company) my health care information including diagnostic test results and medical test results.
- I understand that this diagnostic test is for informational purposes only. This facility will not admit patients or provide medical advice.
Patient Signature

Clear
Date Signed

MonthDayYear
Date
TESTING DATE

MonthDayYear
Date

My Products
prevnext( X )
RT-PCR (Results 60 minutes)FOR A FAMILY OF TWO , YOUR RESULTS WILL BE READY UNDER 1 HOUR,HOWEVER DUE TO HIGH DEMAND YOURS RESULTS MAY TAKE 1-2 HOURS, PLEASE TALK TO THE ADMINISTRATOR IF YOU HAVE AN EMERGENCY SITUATION
$145.00 Number of family members

Total

$0.00
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COVID-19 RT-PCR Form

Appointment Schedule

Patient Demographic Information

Patient Health Information

Acknowledgment and Consent