COVID-19 TEST

COVID-19 TEST
Which testing option would you like to receive?
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/PositiveNot detected/NegativeInconclusive/Undetermined/Invalid/Equivocal
Type of Facility

Pharmacy
Specimen Type

Nasopharyngeal swabNasal swab
Test Name

ACCULA SARS-CoV-2 (COVID-19) Rapid PCR TestingCareStart COVID-19 Rapid Antigen testQUICKVUE SARS ANTIGEN TEST
Patient Name*

First nameMiddle nameLast name
Date of birth (MM/DD/YYYY)*

MonthDayYear
Date
Phone Number*
Address*

Street Address (and unit/apt # if applicable)

Street Address Line 2

CityState

Zip code
Sex at birth*

MaleFemaleN/A
Select the most appropriate status below regarding pregnancy*

PregnantPostpartumUnknownNeither pregnant nor postpartum
Race (select all that apply)*

American Indian or Alaska NativeAsianBlack or African AmericanNative Hawaiian or other Pacific IslanderWhiteOther race (specify)
Ethnicity*

Hispanic or LatinoNot Hispanic or LatinoUnknown
Do you have any symptoms?*

YesNoUnknown
List your symptoms (if applicable)

Fever or chillsCoughShortness of breath or difficulty breathingFatigueMuscle or body achesHeadacheNew loss of taste or smellSore throatCongestion or runny noseNausea or vomitingDiarrheaOther
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*

Clear

My Products*

PCR TEST(RESULTS WITHIN 30 MINUTES) APPROVED FOR TRAVEL WITH QR CODE

$125.00

ANTIGEN TEST(RESULTS WITHIN 10-15 MINS)

$50.00

Enter coupon

Total

$0.00

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
Should be Empty: