G & R Pharmacy Patient Intake CovidTest Form

RAPID COVID-19 Testing Consent Form. CALL 352-628-0096 TO CONFIRM TEST AVAILABILITY DUE TO HIGH DEMAND AND SHORT SUPPLY

SELF PAY ONLY. WE DO NOT BILL INSURANCE.
Accession ID
Facility name
Address

Facility address

Street Address Line 2

City State

Zip code County
Phone
CLIA#10D2193296
COVID-19 Testing Appointment
Section 2: Patient Information
Name*

Frist Name Last Name
Address*
City*
State*
Zip Code*
County*
SEX*

MaleFemaleNeither/Other
Pregnant (YES or NO)*
Date of Birth (MM/DD/YYY)*

MonthDay Year
Date
Age (years)
Phone Number: *
Race (select all that apply)*

AsianAmerican Indian or Alaska NativeBlack or African AmericanNative Hawaiian or other Pacific IslanderWhiteUnknown
Ethnicity*

Hispanic or LatinoNonHispanic or LatinoUnknown
What is the patient's affiliation to the facility?

ResidentStaffVisitorPatientStudentClientInmate
Symptoms of COVID or COVID like reported:

CoughFever/ChillsSore ThroatLoss of TasteRunny NoseShortness of BreathOther
Do you know Date when your Symptom Started if any. NOTE: Rapid Antigen Tests are best utilized for detection around 4 to 5 days after exposure/infection. PCR Molecular Tests can detect infection within 24 hours of exposure/infection.

YESNO
If Known, please enter the Date when symptoms started. NOTE: If Less then 48 hours we advice to get PCR Test(we do not currently offer)

MonthDay Year
Date
Type of Vehicle you will be in at curbside? (PLEASE MAKE SURE TO INCLUDE MAKE, MODEL AND COLOR) & CALL US WHEN YOU ARRIVE at 352-628-0096. Please give us few minutes to attend you.
Do you have any School Association? If do please select one of the following:

TeacherOtherFaculty/StaffStudent
School Name if any association
Terms & Conditions
I certify that I am:
(a) The Patient and at least 18 years of age or
(b) The Parent or legal guardian of the patient.
Further, I hereby given my consent:
To the healthcare provider of G & R Health Mart Pharmacy, as applicable (each an "applicable Provider"), to administer the COVID-19 test(s) I have requested above. I understand that it is not possible to predict all possible side effects or complications associated with receiving a COVID-19 test(s). I understand the risks and benefits associated with the above COVID-19 test(s) and have received, read, and/or had explained to me the information pertaining to the COVID test(s) I have selected and all of my questions have been answered by a G & R Helath Mart Pharmacy staff member to my satisfaction. On behalf of myself, my heirs and personal representatives, I hereby release and hold harmless the applicable Provider, its staff, agents, successors, divisions, affiliates, subsidiaries, officers, directors, contractors and employees from any and all liabilities or claims whether known or unknown arising out of, in connection with, or in any way related to the administration of the COVID test(s) listed above. For travel purpose we will provide form with results. If you require specific/special documents you will be responsible to find out if our document will be accepted.
I Further Agree:
To be fully financially responsible for the full cost of this COVID test(s) as listed above. I understand that any payment for which I am financially responsible for is due prior to the time of service, for which the G & R Health Mart Pharmacy healthcare Provider will provide receipt of such invoice. There are no refunds once acknowledgment and payment information has been made. I agree to come in for testing and will not be issued any refunds for any reason whatsoever once I have agreed to these terms.
*

I have read and agree to all the terms above *
Signature

Clear
Patient identifier (if applicable)

N/AMedical Record NumberPatient Internal IDPublic Health Case IDSpecimen IdentifierPatient External IDOther (specify):
RAPID ANTIGEN TESTFaStep Rapid COVID-19 IgG/IgM Antibody
Specimen type

Capillary bloodNasal SwabNP(nasopharyngeal swab)Other(Specify)
Test Result

ANTIGEN POSITIVEIgG/IgM POSITIVENegativeInconclusive/Invalid/Undetermind
Device identifier(Lot #)
Specimen collection date (MM/DD/YYYY)

MonthDay Year
Date
Test Result Submitted(MM/DD/YYYY)

MonthDay Year
Date
Should be Empty:

RAPID COVID-19 Testing Consent Form. CALL 352-628-0096 TO CONFIRM TEST AVAILABILITY DUE TO HIGH DEMAND AND SHORT SUPPLY