COVID TEST

Point of Care Testing for COVID-19

Patient Intake and Assessment Form
Please Select a COVID-19 Test *
PCR LAB TEST - Insurance will be billed. Cash price is $125 for no insurance.
Appointment *
Appointments must be before 11:50 am to go out same day. Generally, results are available the following day after your kits are shipped but can take up to 2 days.

Friday appointments after 11:50 am won't be shipped until Monday and results won't come until Tuesday or Wednesday.
FOR LAB TESTS: Click on the following link to make an account with the lab PRIOR to your appointment time. If possible, bring a device to access this account during your appointment.

https://srs.nolims.app/users/sign_up?access_code=CAMDEN
Email
example@example.com
Name *

First Name Last Name
Date of Birth *

Month Day Year
Date
Gender
Social Security Number: blanks
Race
Ethnicity
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number *
Please enter a valid phone number.
Primary Care Physician: Doctor Name Street Address City State Zip
When did your symptoms start?

Month Day Year
Date
Which symptoms do you currently have? *

Fever Headache Runny Nose Head/Nasal Congestion Muscle Pain Cough Sore Throat Fatigue Loss of Taste and/or Smell None
Have you taken any medications for these symptoms?

No If yes, what?
Have you been exposed to COVID-19 in the last two weeks? *

Yes No
Did you get a flu shot this year?

Yes No
Have you had a COVID-19 vaccine?

Yes No

Signature

Clear
Date *

Month Day Year
Date
Please park in our back parking lot and call us when you arrive for your test!
{appointment}Thank You!

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PHARMACY USE: COVID-19 Results
PHARMACY USE COMBO:

DATE:{appointment}
TEST PERFORMED BY: _________________

SPECIMEN/MESSAGE CONTROL ID: CVP_______________
USE FORMAT: CVPYEARMMDDXXX

TEST INFORMATION:

BD Veritor
LOT: 1197693
EXPIRATION: 10-19-22
RESULTS:

SARS-CoV-2 (COVID-19): Positive / Negative

Flu A: Positive / Negative

Flu A: Positive / Negative

PHARMACIST INITIALS: _________

RECCOMENDATIONS: ______________________________________
Should be Empty:

Point of Care Testing for COVID-19