Antibody Test Registration

COVID-19 Antibody Test Registration

Your reservation is not held until you complete your registration successfully and receive a GREEN CHECK MARK at the end. In order to guarantee 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. Rapid Antibody Test - A COVID-19 antibody test is a rapid test done through a finger stick blood sample that can detect the presence of COVID-19 antibodies in your bloodstream. Results are available in 15-30 minutes.

3. The cost of a COVID-19 Antibody test is $39(discounted from $60). We cannot bill your medical insurance for the testing as we can only bill prescription plans at the pharmacy and testing is not covered by your prescription plan. 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 is not responsible in the event your insurance does not 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

5. Results are EMAILED to you after the test within 15-30 Minutes.

Appointment

Patient Full Legal Name*

DOB*

Phone*

Gender*

MaleFemale

Email*

Please double check and ensure this is accurate otherwise an email will be sent to the incorrect email address you have provided.

Address*

Address

Street Address Line 2

CityState

Zip

How did you hear about us?*

Ethnicity

Race

Have you been diagnosed positive with COVID-19? If so please write the date*

Have you had close contact with someone who has COVID-19 in the past 14 days?*

Have you been feeling feverish or had a fever higher than 100.5F in the past 3 days?*

Type a question*

I hereby grant permission to Lititz Apothecary to perform certain screening tests as set forth below at my direction, which may include obtaining specimens of mucus by nasal, nasopharyngeal or oropharyngeal swab or blood by venipuncture or finger stick. I authorize Lititz Apothecary to obtain these screening results and provide them to me via phone, email or mail. I agree to pay for the tests in full at the time of service I understand that the testing has not been ordered by a physician and is being done for my own use and not for medical diagnostic or treatment purposes. Because the tests are not ordered by a physician, insurance coverage may not be available, including Medicare or Medicaid. Upon your request, Lititz Apothecary or its affiliates may submit the tests to any insurance company for reimbursement However, if insurance does not reimburse due to any reason, I understand that I will be responsible for the Usual & Customary charge for these tests. I further understand that the test results will not be forwarded to any medical profession al for diagnosis of any medical condition. It is my responsibility to share the test results with my physician at my sole option. I, alone, am responsible for obtaining medical information, treatment or services from a doctor or other health care provider in relation to test results. I authorize Lititz Apothecary to report the administration of this test to the state per regulations. I understand the state may use my information and contact me for any purpose deemed necessary. I understand these tests have not been cleared or approved by the FDA and all these tests have been authorized by FDA under EUA's for use by authorized laboratories. I have been provided with, read and understood the patent handouts or factsheets for these tests. I understand the risks, limitations, nature of these tests. I hereby and for my heirs, executors, administrators, successors and assigns release, acquit and forever discharge Lititz Apothecary, its subsidiaries and affiliates, and each of their agents, employees, officers, directors, servants, successors, heirs, executors, and administrators, (collectively. "Lititz Apothecary"), of and from any and all claims, actions, causes of action, demands, rights, damages, injuries and property damage and the consequences there of resulting or to result from the testing. I acknowledge that I have read this release form prior to signing it and that I understand its contents. I understand and agree that I will not be able to sue MSS for any injury or property damage I may suffer as a result of the testing. I HEREBY CERTIFY THAT I HAVE READ THE ABOVE ACKNOWLEDGEMENT AND HAVE HAD AN OPPORTUNITY TO ASK QUESTIONS ABOUT ITS CONTENTS BY SIGNING BELOW. I CONSENT TO UNDERGO THE SELF-DIRECTED LABORATORY TESTING UNDER THE CONDITIONS SET FORTH HEREIN.

Patient/Guardian Signature*

Date*

Date

DURING YOUR APPOINTMENT:

Come inside the pharmacy if you don't have any COVID-19 symptoms.
Please inform the team member your
- 1) First & Last Name
- 2) You are here for your ANTIBODY TEST
- 3) If you paid in advance via credit card or paying cash in person. One of our team member will bring out the kit.
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-6:30PM 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 30 minutes (also keep an eye out in your spam folder), please call the store 717-626-2222 with your name, test taken, and time of your appointment.

My Products*

COVID-19 Antibody Test

$39.00

Total

$0.00

Credit Card

Payment

Credit Card