Payment Collection 

Once you submit this form a staff member will contact you before your selected appointment time to finalize your appointment. At this time they will also collect the nonrefundable fee of $80.00. This fee will not be billed to insurance.

 

Appointment Information

All appointment times are not final or confirmed until the pharmacy has contacted you and received payment.

At the time of your appointment, please stay in your car and give us a call to let us know you've arrived. A staff member will come out to perform the test from the comfort and safety of your vehicle.  

 

Our Address:
2409 Box Butte Ave.
Alliance NE, 69301 

CONSENT FOR STREP TESTING

If you have any questions about the following statements, please contact us at 308-629-1045.

You will receive a paper copy of this form at the time of your appointment.

 

 

To proceed with receiving the Abbott ID Now Rapid Molecular Group A Strep test I confirm and understand the following:

The ID Now Molecular Strep Testing will not be submitted to insurance.

I understand that in general, strep throat is a generally mild infection , but it can be very painful.  The most common symptoms of strep throat include:  Sore throat that can start very quickly, pain when swallowing, fever, red and swollen tonsils, sometimes with white patches or streaks of pus, tiny, red spots on the roof of the mouth, swollen lymph nodes in the front of the neck.  Once exposed to group A Strep it usually takes 2 to 5 days for someone to become ill.

I understand that I am the decision-maker for my health care.  To the best of their ability, Alliance Community Pharmacy will provide me with information to assist me in making informed choices. This process is often referred to as “informed consent” and involves my understanding and agreement regarding recommended care, and the benefits and risks associated with group A Strep testing.  I understand that it is possible to get a “false-negative” group A strep test.

I understand that preventative measures and intensified sanitation protocols are in place at Alliance Community Pharmacy.  However, because this work involves close physical proximity, there may be an elevated risk of disease transmission.  I hereby give my express permission to the staff at Alliance Community Pharmacy to proceed with Rapid Molecular Strep Testing.

I have been offered a copy of this consent form.

I knowingly and willingly consent to the testing with the full understanding and disclosure of the risks associated with testing.  I confirm all of my questions were answered to my satisfaction.  I have read, or have had read to me, the above consent to test. I have also had the opportunity to ask questions about its content and by signing below, I agree with the current or future recommendation to receive testing as is deemed appropriate for my circumstance.