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/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 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 *

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: