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  • SARS CoV-2 Antigen Assay (Rapid Covid-19) Test Form

  • HEALTHCARE FACILITY INFORMATION

  • Name of Laboratory: Doc's Pharmacy, Inc.

    Address: 2860 Freedom Drive, Charlotte, NC 28208

    Phone Number: 704.900.6001

    CLIA ID: 34D2245254

  • Note: Test results will be sent via email. 

  • PATIENT INFORMATION

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  • Special instructions for minors:

    • Age 3-15:  Parent or legal guardian needs to fill out form and accompany patient.
    • Age 16-17: Parent or legal guardian needs to fill out form only.
  • COVID-19 ASSESSMENT

    All fields are required to be completed unless marked optional
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  • DISCLAIMER

    If you have tested negative today and experiencing symptoms, please come back to be re-tested. If you have tested positive, a re-test will not be administered on the same day.
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