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COVID-19 Antibody Test

Please carefully read and fill out this form to book your Antibody Test. This is a non-diagnostic test to tell you if you've had COVID-19 in the past!
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    Please verify that you understand:

    When submitting 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 $89.95. This fee will not be billed to insurance. 


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    Please provide city and state
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    Which of the following symptoms are you experiencing?
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    In the past, have you have a positive COVID-19 diagnosis from a PCR or Antigen test?
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    Please tell us the date or month of your positive diagnosis and which test was performed. (PCR or Antigen Test)
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    COVID-19 Antibody Testing Information 

    Antibody tests should not be used to diagnose a current COVID-19 infection. It is very important that you are not tested too soon. It can take 2-3 weeks to develop enough antibodies to be detected in an antibody test, with the peak time for testing being 3 or more weeks after infection occurs.

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    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 $89.95. 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 

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    Consent for 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 test, I confirm and understand the following.

    I understand that the novel Coronavirus (COVID-19) has been declared a global pandemic by the World Health Organization (WHO). I further understand that COVID-19 is extremely contagious and may be contracted from various sources. I understand COVID-19 has a long incubation period during which carriers of the virus may not show symptoms and still be contagious. 

    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 testing during the pandemic. Given the current limitations of COVID-19 virus testing, I understand determining who is infected with COVID-19 is exceptionally difficult.

    I understand that preventative measures and intensified sanitation protocols intended to reduce the spread of COVID-19 have been implemented. However, because this work involves close physical proximity, there may be an elevated risk of disease transmission, including COVID-19. I hereby give my express permission to you and the staff at Alliance Community Pharmacy to proceed with rapid antibody 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 DURING THE COVID-19 PANDEMIC. I CONFIRM ALL OF MY QUESTIONS WERE ANSWERED TO MY SATISFACTION. I HAVE READ, OR HAVE HAD READ TO ME, THE ABOVE RAPID ANTIBODY INFORMED CONSENT TO TEST. I HAVE ALSO HAD AN 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.

     

    If you are under the age of 18 please have a parent or guardian approve these terms on the next slide. A parent or guardian must be present at the time of your appointment.

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    Please type your full name to confirm that you have read and fully understand the terms stated in the previous slide.
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    Please select a time for your appointment. Remember to write it down or add it to your calendar! The appointment fee is non-refundable.
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