COVID Test Consent Form - Damm Pharmacy

COVID Test Consent Form

We are currently offering rapid (nasal) testing.
If you have remaining questions, please call us at (316)788-5533.
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:
MaleFemale
YesNoUnsure
Hispanic or LatinoNon Hispanic/LatinoUnknownPrefer not to answer
African AmericanAmerican IndianAsianCaucasianNative Hawaiian/Other Pacific IslanderPrefer not to answerOther
Address:*

Street Address Line 2
Primary Care Doctor:*
Doctor City/State:*
Rapid Antigen Test (Nasal swab - results in 30 minutes)
YesNo
YesNo
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
YesNoUnsure
Approximately how many days ago were you exposed?
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.
Should be Empty: