COVID-19 TEST
Which testing option would you like to receive?
Please Select
PCR TEST: $125 (RESULTS WITHIN 1-2 HOURS) APPROVED FOR TRAVEL WITH QR CODE
ANTIGEN RAPID TEST: $50 (RESULTS WITHIN 10-15 MINS)
Select your COVID-19 Testing Appointment Time
*
Submitter Name
Facility Name
Facility Address
Facility City
Facility State
Facility Zip Code
Facility County
Facility Phone
Facility CLIA Number
Submitted Test Result to State [MONTH (MM)] - Post Test
Submitted Test Result to State [Day (DD)] - Post Test
Submitted Test Result to State [YEAR (YY)] - Post Test
Pharmacist Name (ordered the test)
Pharmacist NPI
Date Swab Performed [MONTH (MM)] - Post Test
Date Swab Performed [DAY (DD)] - Post Test
Date Swab Performed [YEAR (YYYY)] - Post Test
Test Result (Post test)
Detected/Positive
Not detected/Negative
Inconclusive/Undetermined/Invalid/Equivocal
Type of Facility
Pharmacy
Specimen Type
Nasopharyngeal swab
Nasal swab
Test Name
ACCULA SARS-CoV-2 (COVID-19) Rapid PCR Testing
CareStart COVID-19 Rapid Antigen test
QUICKVUE SARS ANTIGEN TEST
Patient Name
*
First name
Middle name
Last name
Date of birth (MM/DD/YYYY)
*
/
Month
/
Day
Year
Date
Phone Number
*
Address
*
Street Address (and unit/apt # if applicable)
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
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Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip code
Sex at birth
*
Male
Female
N/A
Select the most appropriate status below regarding pregnancy
*
Pregnant
Postpartum
Unknown
Neither pregnant nor postpartum
Race (select all that apply)
*
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or other Pacific Islander
White
Other race (specify)
Ethnicity
*
Hispanic or Latino
Not Hispanic or Latino
Unknown
Do you have any symptoms?
*
Yes
No
Unknown
List your symptoms (if applicable)
Fever or chills
Cough
Shortness of breath or difficulty breathing
Fatigue
Muscle or body aches
Headache
New loss of taste or smell
Sore throat
Congestion or runny nose
Nausea or vomiting
Diarrhea
Other
Take a photo of your Driver's License/Passport
Email Address
*
example@example.com
Please select your preference for an email notification.
I would like to receive my test results via an unsecured email from the pharmacy that is not HIPAA Compliant.
I DO NOT want to receive my test results via an unsecured email; I will come by the pharmacy to receive a hard copy.
Signature
*
My Products
*
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( X )
PCR TEST
(RESULTS WITHIN 30 MINUTES) APPROVED FOR TRAVEL WITH QR CODE
$
125.00
ANTIGEN TEST
(RESULTS WITHIN 10-15 MINS)
$
50.00
Credit Card
MEDICARE PART B ID# (THE RED, WHITE AND BLUE CARD)
*
Take a photo of your MEDICARE PART B CARD (RED, WHITE AND BLUE CARD)
Date
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