Clone of Covid-19 Test Appointment Form FOR PMP2

Testing Appointment Form

COVID-19 test
Name*

First NameLast Name
Date of Birth*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
Email*
example@example.com
Please check if experiencing any symptoms?*

High feverCoughDifficulty in breathingPersistent pain or pressure in the chestBody achesNasal congestionRunny noseSore throatDiarrheaNone of the above
Have You Been Exposed To Someone With COVID-19?*
Please check all that apply*

AnemiaAsthmaArthritisCancerGoutDiabetesEpilepsy SeizuresHeart DiseaseHeart AttackRheumatic FeverHigh Blood PressureDigestive ProblemsUlcerative ColitisHepatitisKidney DiseaseLiver DiseaseThyroid ProblemsTuberculosisVenereal DiseaseNeurological DisordersBleeding DİsordersLung Disease (Chronic Obstructive Pulmonary Disease)None of the above
By submitting I hereby confirm that the information I have given above is true, and that I will comply with the terms and conditions outlined above.
Appointment
Signature

Clear
PLEASE REMAIN IN YOUR CAR AND CALL US UPON YOUR ARRIVAL. THE PHARMACIST WILL APPROACH YOUR CAR AND DO THE TEST. PHONE NUMBER OF THE PHARMACY: 818-548-1330.

My Products

COVID-19 RAPID ANTIGEN TEST$79.00

PACIFIC MEDICAL PHARMACY, INC IS NOT ABLE TO BILL COVID-19 ANTIGEN TEST TO PATIENT'S INSURANCE.

Total $0.00

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Testing Appointment Form