COVID TEST FORMS

AMIABLE PHARMACY

1108 LIBERTY AVE

BROOKLYN, NY 11208

T: 718-827-7528 F: 718-277-0193
Name

First NameLast Name
DATE OF BIRTH

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
ADDRESS
PHONE NUMBER
Please enter a valid phone number.Format: (000) 000-0000.
EMAIL
example@example.com
GENDER

Other
Do we have permission to contact you about your TEST RESULTS?
Do you have a primary care doctor?
PCP Name
PCP Phone #
Format: (000) 000-0000.
Do you have Insurance?
INSURANCE Company Name
INSURANCE ID
INSURANCE Group
Policy Holder's name
Policy Holder's DOB
Are you experiencing ANY of the following symptoms? ( Sore throat, Cough, Fever, Shortness of breath, Diarrhea, Headache, Body aches, Nausea/Vomiting, Loss of taste or smell )
Which symptoms?
2. Has anyone in your HOUSEHOLD, or ANY of your ACQUAINTANCES tested POSITIVEfor COVID-19 within the last 14 days?
3. Any recent travel outside the State or Country?
I voluntarily consent and authorize Amiable Pharmacy to conduct collection, testing, and

analysis for COVID-19 through a nasopharyngeal swab, as ordered by Nusrat Mitu, NP.
Signature of Patient/Guardian
Today's Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
PHOTO ID VERIFIED?
PHOTO ID

Cancelof
Should be Empty: