• Covid Rapid Test Application

    Applicant Information
  • Format: (000) 000-0000.
  • Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • INSURANCE INFORMATION

    If you have Insurance please submit Information:
  • Pick one of the following options below*
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  • Format: (000) 000-0000.
  • ID INFORMATION

  • Pick one of the following options below*
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  • Expect to receive your results within approximately 15 minutes. Your results will be provided verbally and/or via text. Emailed results may take up to 24 hours and will come from BesScription@gmail.com email address. If you do not receive an email in your inbox, please be sure to check your spam or junk folder.

  • Informed Consent for COVID-19 Testing

  • Please carefully read the following informed consent:

    a. I authorize this COVID-19 testing unit (BesScription Pharmacy) to conduct collection and testing for COVID-19 through a nasopharyngeal swab. Collecting a specimen for testing involves inserting a small swab, similar to a Q-Tip, into the front of the nose.

    b. I authorize my test results to be disclosed to the county, state, or to any other governmental entity as may be required by law.

    c. I acknowledge that a positive test result is an indication that I must continue to self-isolate in an effort to avoid infecting others.

    d. I understand the testing unit (BesScription Pharmacy) is not acting as my medical provider. Testing does not replace treatment by my medical provider. I assume complete and full responsibility to take appropriate action with regards to my test results. I agree I will seek medical advice, care and treatment from my medical provider if I have questions or concerns, or if my condition worsens.

    e. I understand that, as with any medical test, there is the potential for false positive or false negative test results.

    f. I, the undersigned, have been informed about the test purpose, procedures, possible benefits and risks. I have been given the opportunity to ask questions before I sign, and I have been told that I can ask other questions at any time. I voluntarily agree to testing for COVID-19.

    g. I allow the vendor to test my child weekly or as required by their school until February 28th 2022

  • Todays date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Area Below to be Completed by BesScription Representative

  • Date
     - -
    2 digit month, 2 digit day, 4 digit year
  • 460 Glen Cove Avenue, Sea Cliff, NY 11579  |  866-237-9419  |  BesScription@gmail.com

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