COVID-19 Rapid PCR Test Appointment & Consent Form
Same Day Results; Costs $150.00
Select a 15-minute time slot for your COVID-19 Testing Appointment
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Name
*
First name
Last name
Date of birth (MM/DD/YYYY)
*
/
Month
/
Day
Year
Date
Gender
Male
Female
Other
Race (select all that apply)
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American Indian or Alaskan Native
Asian
Black or African American
White
Unknown
Other
Ethnicity
Hispanic or Latino
Not Hispanic or Latino
Address
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Street Address
Street Address Line 2
City
State
Zip
Phone
*
Email address
Date of Onset (MM/DD/YYY)
*
Hospitalization
Yes
No
Unknown
Did the Patient Die?
Yes
No
Unknown
Date of death (MM/DD/YYYY)
/
Month
/
Day
Year
Date
Specimen collected date (MM/DD/YYYY)
/
Month
/
Day
Year
Date
Test completed date (MM/DD/YYYY)
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Month
/
Day
Year
Date
Type of test
Nucleic acid detection (rRT-PCR)- Accula
IgM antibody
IgG antibody
Antibody (IgM, IgG, not specified)
Antigen detection- BD Veritor
Test Result
Positive
Negative
Inconclusive
Indeterminate
Ordering Provider
Please Select
Spero Stefanis
Jillian Bowker
Provider NPI
Please Select
Spero: 1194295428
Jillian: 1740750082
How would you like to receive your results?
*
Phone
Email (not HIPAA-compliant)
Other
Instructions for arriving at your appointment:
Please check in at pharmacy drive-thru at the time of your appointment.
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