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

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
Test Name:

Rapid COVID-19PCR
Note: Test results will be sent via email.
PATIENT INFORMATION
Patient First Name
Patient Middle Initial
Patient Last Name
Patient Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Patient Date of Birth

MonthDayYear
Example: 12-01-1990
Patient Gender
Patient Race
Patient Email
Patient Phone
Relationship to Patient
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.
Take Photo of Patient Driver's License (Front)
Take Photo of Patient Medical Insurance Card (Front)
COVID-19 ASSESSMENT

All fields are required to be completed unless marked optional

Have you experienced any of the following symptoms of COVID-19?

	Yes	No
Fever or chills
Cough
Shortness of breath or difficulty breathing
Fatigue
Weakness
Sore throat
Nausea or vomiting
Diarrhea
Have you received a COVID-19 vaccine?
Is this your first time taking the COVID-19 test?
Have you tested positive for COVID-19 in the past 10 days?
Are you currently awaiting results from a COVID-19 test?
If applicable, are you currently pregnant? (optional)

Patient Signature - I acknowledge that I have answered these questions stated above truthfully to the best of my knowledge. I consent to testing for COVID-19 and agree to these terms.

Clear
Today's Date

MonthDayYear
Date
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.
Patient Test Result (Internal Use Only)

NegativePositive
Treatment Date (Internal Use Only)

MonthDayYear
Date
Should be Empty:

HEALTHCARE FACILITY INFORMATION