COVID-19 Test Appointment and Consent Form

COVID-19 Antigen Test Appointment

Avoid the long lines! Results within 1 hour. The cost is $60, insurance not accepted. You will receive your results via phone and also from the FL Department of Health via text message.
This Service is for Solivita Residents and Family Only
Select your COVID-19 Testing Appointment Time! *
Patient Name *

First name Middle name Last name
Date of birth (MM/DD/YYYY) *

Month Day Year
Date
Age *
Address *

Street Address (and unit/apt # if applicable)

Street Address Line 2

City

Zip code
State *
You may choose a different option if your State is different
Phone Number *
Sex at birth *

Female Male Neither/Other Unknown
Select the most appropriate status below regarding pregnancy *

Pregnant Postpartum Unknown Neither pregnant nor postpartum
Race (select all that apply) *

Unknown 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
Email Address *
example@example.com

Payment *

Rapid Antigen Test You will receive your test results on the same day, within 1 hour of test completion.

$ 60.00

Total

$ 0.00

COVID-19 Antigen Test Appointment