COVID-19 TEST SCREENING FORM
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Gender
*
Male
Female
Other
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Cell Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
What are the symptoms you're currently experiencing?
*
Fever
Lethargic (Tiredness)
Restlessness
Dry cough
Body ache
Nasal Congestion
Runny Nose
Loss of Smell
Diarrhea
Loss of Appetite
Other
Asymptomatic (No Known Symptoms)
Appointment
*
My Products (You can select more than 1 test at a time)
*
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RAPID RT-PCR (MOST COMMONLY USED FOR TRAVEL)
Usually results within 2 - 3 hours
$
200
RAPID ANTIGEN TEST
Usually results within 15 minutes But might take 2-3 hours - due to high volume
$
60
COVID-19 + FLU
Usually results within 15 minutes But might take 2-3 hours - due to high volume
$
90
Credit Card
Do you have insurance?
*
Yes
No
Insurance Card Front Photo (Only required if booking free RT-PCR test)
Insurance Card Back Photo (Only required if booking free RT-PCR test)
Social Security Number
Required if you do not have insurance and booking FREE RT-PCR test.
Acknowledgment and Consent
I acknowlege 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 rock ridge pharmacy to share with the requester my health care information including diagnostic test results and medical test results.
I understand that any payment for which I am financially responsible for is due prior to the time of service, for which Rock Ridge Pharmacy 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.
Patient Signature
*
Clear
Date Signed
*
-
Month
-
Day
Year
Date
Submit
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