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

Rows	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?
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
Collection Date

MonthDayYear
Date
Specimen Collected
If yes, what is the influenza test result?
What type of influenza test?
Have you been tested for COVID-19
If yes, what is the COVID-19 test result?
What type of COVID-19test?
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
Date Signed

MonthDayYear
Date
TESTING DATE

MonthDayYear
Date

COVID-19 RT-PCR Form