COVID Test Consent Form - Damm Pharmacy

COVID Test Consent Form

We are currently offering both rapid (nasal) and PCR (saliva) testing.
If you have remaining questions, please call us at (316)788-5533.

If you would like online access to your PCR results, please enter a valid email address and choose a 4-digit PIN.
Section I. Personal Information
Patient's Full Name *

First NameMiddle NameLast Name
Mother's Maiden Name *
Date of Birth:*

MonthDayYear
Age:*
Phone Number:*
Email:*
Add up to 2 additional family members ( full name and date of birth). You have to make additional appointment for 3 additional people or more.
Enter a FOUR digit PIN if requesting online access for saliva test:
Gender:*

MaleFemale
Are you currently pregnant?*

YesNoUnsure
Ethnicity:*

Hispanic or LatinoNon Hispanic/LatinoUnknownPrefer not to answer
Race:*

African AmericanAmerican IndianAsianCaucasianNative Hawaiian/Other Pacific IslanderPrefer not to answerOther
Address:*

Street Address Line 2
Primary Care Doctor:*
Doctor City/State:*
My preferred test is:*

Rapid Antigen Test (Nasal swab - results in 30 minutes)RT-PCR Test (Saliva test - results within 48 hours unless testing on Saturday then results may not be available till tuesday)Both
Is this your first Covid test?*

YesNo
Do you work in a healthcare setting?*

YesNo
Have you had a COVID vaccine?*

Yes, PfizerYes, ModernaYes, Johnson&JohnsonYes, but only one of two doses of mRNA vaccine (Moderna/Pfizer)No
If you have received a COVID vaccine please list the date of your last dose *

MonthDayYear
Date
Have you had an exposure to COVID-19?*

YesNoUnsure
Approximately how many days ago were you exposed?
What symptoms are you experiencing now? Please check all that apply.*

Fever or ChillsCoughShortness of breathFatigueMuscle or body achesHeadacheNew loss of taste or smellSore throat/hoarsenessNausea or vomitingDiarrheaCongestion or runny noseNo Symptoms
Appointment*
Section IV. Signature

By signing this form, I give consent for Derby Drug to send my testing results to the Kansas State Department of Health and Welfare.
Signature of Person to Receive COVID test (or Signature of Parent/Guardian if Patient is < 18 yo)*

Clear
Name Parent/Guardian

First NameLast Name
Date of Birth of Parent/Guardian

MonthDayYear
Date
By clicking the "Submit" button below, you certify that the above information is correct and accurate to the best of your knowledge. All information is confidential and is accessed only via a secure, encrypted interface.
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