Family Pharmacy Rapid Covid-19 Testing Appointment and Consent Form

By Signing in the box below I am stating the following:

I understand that my personal information and test results will be shared with the Maryland Department of Health. I understand if the person being tested is under 18 years old, a parent or guardian must be present at testing.I understand that the testing apparatus is the Accula Rapid PCR anterior nare test. I consent to being tested by Family Pharmacy, Inc. Facility CLIA ID 21D2208508 and confirm that I am at least eighteen years of age or signing for a minor under the ago of eighteen.

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My Products*

Covid-19 Rapid PCR Test$195.00

PCR test (rapid)

Enter coupon

Total $0.00

I understand that there will be a $10.00 fee on any and all cancellations.*

Yes, I understand I will be charged a $10.00 fee for all cancellations.

INTERNET EXPLORER DOES NOT WORK WITH THIS FORM. PLEASE USE GOOGLE CHROME OR OTHER BROWSER.

Upon submission you will receive an email with all the information that, depending on your insurance coverage, can be submitted for possible reimbursment.

(if you don't see emails(3). Search your email program for Jotform-as it may have gone to your junk/spam folder)

Family Pharmacy does not guarantee that you will be reimbursed for this fee as insurance companies vary in their policies.

Payment Methods

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Please click one of the PayPal options to complete payment and submit the form.

Family Pharmacy of Hampstead

Rapid PCR 1 Hour Testing

All Testing Performed at Drive-Thru ONLY!

The cost of the test is $195.00