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
Date
ADDRESS*
PHONE NUMBER*
Please enter a valid phone number.
EMAIL
example@example.com
GENDER*

MaleFemaleOther
Do we have permission to contact you about your TEST RESULTS?*

YESNO
Do you have a primary care doctor?*

YESNO
PCP Name
PCP Phone #
Do you have Insurance?*

YESNO
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 )*

YESNO
Which symptoms?
2. Has anyone in your HOUSEHOLD, or ANY of your ACQUAINTANCES tested POSITIVEfor COVID-19 within the last 14 days?*

YESNO
3. Any recent travel outside the State or Country?*

YESNO
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*

Clear
Today's Date*

MonthDayYear
Date
PHOTO ID VERIFIED?*

YESNO
PHOTO ID*

Cancelof
Should be Empty: