Antigen (Rapid) Test Registration

COVID-19 Rapid Antigen Test Registration

Your reservation is not held until you complete the registration successfully and receive a GREEN CHECK MARK at the end. In order to confirm your spot, do not navigate away from this page until you've submitted the form.

BEFORE YOU PROCEED

1. Special instructions for minors: 0-15: Parent or legal guardian needs to fill out form and accompany patient to visit. Ages 16-17: Parent or legal guardian needs to fill out form only.

2. Any positive results would need to be followed up with further tests by your doctors. A negative test result is not a 100% guarantee that you do not have COVID-19 and does not guarantee that you will not get it in the future either.

3. The cost of a COVID-19 rapid antigen test is $65 (discounted from $84 for prepayment). We cannot currently bill your medical insurance for the testing. Many of our patients have had success in providing their receipt to the insurance company for reimbursement after the test. We will provide you with a results sheet/invoice which has our Tax ID, NPI, Lab License No, and other pertinent details insurance companies require; however, the pharmacy cannot guarantee that the insurance will reimburse you - please confirm with your insurance company first. The test is non-refundable.

4. Cancelling or rescheduling your appointment: if you make a payment via credit card and cannot make your appointment or no longer need the appointment, you may TRANSFER the appointment to a friend, family, etc. OR you may keep that appointment on file with our pharmacy as a CREDIT which can be used for a future test. To cancel your appointment, you can email Info@lititzrx.com. No refunds are available, but a credit will remain on file for you. If you were going to pay cash in person and need to cancel/reschedule, please email info@LititzRX.com with "CASH TEST" as the subject.

5. Results are EMAILED to you after the test within 30-60 minutes.

6. We recommend checking with the Airline/Country prior to reserving and ensure the required information is present to ensure a proactive approach. Rules changes are very fluid and the patient is responsible for ensuring proper information is present based on requirement.

7. If you want to schedule COVID tests for a family or several people coming in the same car, please select consecutive appointments & you can come together at the first designated appointment you have selected. If coming to test a number of family members, we recommend you come together in the same car when possible, to allow us to expedite your tests.

8. If the test is for a child, the parent of the child can assist with the nasal swab process.

9. Helpful links: Rapid Result Fact Sheet | How the Nasal Swab is Done
Schedule an Appointment
Contact Info
Your contact information is only used for messages about your COVID-19 test. By providing your mobile number/email address, you consent and authorize Lititz Apothecary to communicate your test results when they are available via text/email
Patient Legal First Name *
Patient Legal Last Name *
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number *
Please enter a valid phone number.
Email *
Please double check and ensure this is accurate otherwise an email will be sent to the incorrect email address you have provided.
Confirm your Email for accuracy *
Please double check and ensure this is accurate otherwise an email will be sent to the incorrect email address you have provided. We added this to double check just in case the first is typed in hurry.
Date of Birth *

Month Day Year
Date
How did you hear about us
Demographic Info
The Centers for Disease Control and Prevention (CDC) requires we collect this demographic information. We’re committed to providing equal access to COVID-19 testing. Your gender identity, race, or ethnicity are in no way limiting factors in scheduling your COVID-19 test.
Gender

Male Female
Ethnicity

Hispanic or Latino Not Hispanic or Latino Unknown Prefer not to answer
Race

American Indian/Alaska Native Black, American Native, Hawaiian Pacific Islander Asian White Prefer not to answer Unknown Other
Travel and Exposure
Passport # (Be sure to include letters and numbers) *
Only required for destinations of travel. Type NA if not required
Country/State of issuing passport or Drivers License
Type
In the last 72 hours, have you had any of these symptoms? (please check all that apply) *

Fever Chills Shortness of breath or difficulty breathing Fatigue Muscle or body aches Headache New Loss of taste of smell Sore Throat Congestion or runny nose Nausea Vomiting Diarrhea None
Consent and Acknowledgement

Please read the consent below. I voluntarily consent and authorize Lititz Apothecary to conduct the collection, testing, and analysis for the purposes of a COVID-19 diagnostic test for myself and/or my child(ren) and/or my legal dependent(s) as applicable. I understand that the type of test I am signing up for is a COVID-19 rapid antigen testing. The test will consist of a self-collected nasal swab. To the fullest extent permitted by law, I hereby release, discharge, and hold harmless, Lititz Apothecary, without limitation, any of their respective partners, officers, directors, employees, representatives, and agents from any and all claims, liability, and damages, of whatever kind or nature, arising out of or in connection with any act or omission relating to my COVID-19 diagnostic test or the disclosure of my COVID-19 test results to my Employers and other Government Agencies. I understand and agree that my COVID-19 test results may be sent to me by text message, telephone, or email by Lititz Apothecary or any third-party organization, and I authorize the disclosure of my COVID-19 test results to such organization. Should you require treatment from a health care provider that participates in one of these exchanges who does not have your medical records or health information, that health care provider can use the system to gather your health information to treat you. For example, he or she may be able to get a laboratory or other tests that have already been performed or find out about treatment(s) that you have already received. I have read the contents of this form in its entirely and voluntarily consent to undergo diagnostic for COVID-19 testing and release of the result to my employer and other government health agencies. Any positive results would need to be followed up with further tests by your doctors. A negative test result is not a 100% guarantee that you do not have the Covid-19 infection and does not guarantee that you will not get it in the future either. Repeated test may be needed as clinically indicated. The information provided above is true to the best of my knowledge
*

I agree to perform my COVID-19 rapid testing (if for a child, the parent/family member may assist). All information I provided is true and correct.
*

By checking this you understand and agree that the test is NON-REFUNDABLE. You will not call/email to ask for a refund in the event you cancel or do not need the appointment anymore. Due to higher demand and limited appointment availability by checking here, I am aware that the COVID-19 repaid antigen test is NON-REFUNDABLE. If you cannot make your schedule appointment time you may use your same appointment at a different time or transfer the appointment to a family member or friend. You do not need to call us to inform us
*

I agree that I do not hold the pharmacy responsible if the insurance rejects or denies payment for the insurance company, if need be; however, the pharmacy is not responsible for submitting any or assisting me with submitting any information to my insurance company.
*

I understand that I am scheduling to receive for COVID-19 for myself or a minor on whose behalf I am authorized to provide consent. I have reviewed the COVID-19 Rapid result face sheet external link and instructions to see how swabbing is performed external link. I consent to testing for COVID-19 and agree to these terms. Click next after selecting the box.
Patient Signature ( Parent's Signature in case of minor) *

Clear
Date *

Month Day Year
Date
DURING YOUR APPOINTMENT:
- Park in the pharmacy parking lot and call 717-626-2222 and follow the prompts.
- Please inform the team member your 1) First & Last Name, 2) You are here for your RAPID ANTIGEN TEST, 3) If you paid in advance via credit card or paying cash in person. One of our team member will bring out the nasal swabs.
- How to perform the test: Insert the nasal swab in EACH nostril, go high up until you feel a tickle or sensation and twirl or circle 3-5 times. Insert that nasal swab back into the sleeve it came out of. Once completed, please pass the nasal swab back to our team.
- Once you pass the Nasal Swab back to our team in its sleeve, you are ready to go. Our team will EMAIL you the results as soon as they are processed.
- Please do not arrive earlier than 5 minutes prior to your appointment time. If you need to come earlier or later, you do not need to call or email to inform us, you can come between 9:30AM-6:20PM M-F or 930AM-2PM Sat at Lititz Apothecary 100 East Main St. Lititz PA 17543.
- If for any reason, you do not receive a EMAIL within 1-2 hours (also keep an eye out in your spam folder), please call with your name, test taken, and time of your appointment.
Payment

The cost of the test and lab fees is $65 per test (our pharmacy cannot bill medical insurance; therefore, patients are responsible for the testing fee up front). Your test is discounted from $84 to $65 per test.

My Products *

Rapid Antigen Test (Performed by our CLIA-Medical Lab) $65 per test

$ 65.00

Total

$ 0.00

Credit Card

Should be Empty:

Travel and Exposure

Consent and Acknowledgement

Payment

Credit Card