COVID-19 Testing-PharmRx Pharmacy

COVID-19 Testing

RT-PCR (Nasal swab)
Appointment (REQUIRED)
* Please choose a date and time for your appointments *
Patient Information (REQUIRED)

Test will not be performed without ALL required patient information!
Date of Specimen Collection

Month Day Year
Date
Time Collected
Legal Name(First) *
(Last) *
(MI)
Patient's Cell Number (REQUIRED) *
Home Phone Number
Patient's Email (REQUIRED) *
example@example.com
Street Address
City
State
Zip
DOB (MM/DD/YYYY) *
Sex *
SSN#
(SSN# required for uninsured patients only)
If the patient is traveling, please fill:
Travel Date

Month Day Year
Date
Airline
Vaccination History *

Not Yet Vaccinated Fully Vaccinated
Vaccination completion date

Month Day Year
Date
Brand of Vaccine
Employer/School/College Information (REQUIRED)
Contact Number

Not Applicable
Name
Address
Contact Number
Occupation
Race & Ethnicity - Select all that apply (REQUIRED)
American Indian or Alaskan Native Asian Hispanic or Latino Native Hawaiian or Pacific Islander White Not Hispanic or Latino Black or African American Do not wish to disclose:
Insurance Information
Policyholder Name
Insurance Name
Policy #
Group #
Bill Insurance Self Pay Bill Client
CC Report to/ Surgery Center (Optional)
Date of Procedure

Month Day Year
Date
Surgery Center Name
Address
City, State Zip
Preoperative COVID-19 screening procedure
Physician Performing Procedure
Patient Signature: I authorize the release of medical information related to services provided herein to my health plan/ insurance carrier and authorize payment directly to QDx Pathology Services and/or lab services provider. I assume responsibility for payment of charges not covered by my healthcare insurer.
Patient Signature

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COVID-19 Testing

Appointment (REQUIRED)

Patient Information (REQUIRED)

Employer/School/College Information (REQUIRED)

Race & Ethnicity - Select all that apply (REQUIRED)

Insurance Information

CC Report to/ Surgery Center (Optional)