Covid Flu Combo and Strep Test Registration

RAPID Covid Flu A/B Combo and Strep 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.

2. 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.

3. 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

4. Results are EMAILED to you after the test within 1hour

5. We ask that you park and stay in the vehicle and call the store at 717-626-2222 and we will come out to your vehicle.

6. If you want to schedule COVID tests for a family or a number of people coming in together, please select consecutive appointments & you can come together at the first designated appointment you have selected.

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

8. Helpful links: Rapid Result Fact Sheet | How the Nasal Swab is Done

9. If using for travel PLEASE BRING YOUR PASSPORT IF THIS WILL BE REQUIRED BY YOUR ARRIVING DESTINATION.
Which test are you looking to have completed *

Covid Flu A/B Combo Strep
Appointment
Patient Full Legal Name *
NOTE: IF USING FOR TRAVEL THIS MUST MATCH YOUR PASSPORT
DOB *

Month Day Year
Date
Phone *
Passport Number (if not required write "NA")
Enter Your Passport Number for Travelling purpose (bring with you at appointment)
Gender *

Male Female
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

City State

Zip
Ethnicity
Race

SARS CoV-2 Survey *

	Yes	No	Unsure
I have tested + for COVID Antibody in the past
Is this your first COVID Test?
I have test Positive (+) for COVID Antigen in Past
I have traveled outside of state in last 14 days
I have been in contact with someone with COVID-19 in last 14 days

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 Sore Throat Congestion or runny nose Nausea, Vomiting, Diarrhea Cough Loss of Smell None (Travel or work or other) Suspected Exposure, congregate Exposure to covid-19 Patient Suspected Exposure, Not inahled
*

I understand that I am scheduling to receive testing 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.
*

I hereby grant permission to Lititz Apothecary (LA) 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 LA 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, LA 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 LA 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 LA, its subsidiaries and affiliates, and each of their agents, employees, officers, directors, servants, successors, heirs, executors, and administrators, (collectively. "LA"), 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 LAfor 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 SIGNINGBELOW. I CONSENT TO UNDERGO THE SELF-DIRECTED LABORATORY TESTING UNDER THE CONDITIONS SET FORTH HEREIN.
Patient/Guardian Signature *

Clear
Date *

Month Day Year
Date
DURING YOUR APPOINTMENT:
- Please park in the pharmacy parking lot and call 717-626-2222 option 3
- Please inform the team member your
  - 1) First & Last Name
  - 2) You are here for your Combo or Strep test
  - 3) If you paid in advance via credit card or paying cash in person. One of our team member will be out.
- 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 1-2 hours (also keep an eye out in your spam folder), please call the stare at 717-626-2222 with your name, test taken, and time of your appointment.
Payment

The cost of the test and lab fees cannot bill medical insurance through the pharmacy; therefore, patients are responsible for the testing fee up front).

Covid Flu A/B Combo

$ 90.00

Strep Rapid Strep

$ 45.00

Total

$ 0.00

Credit Card

How did you hear about us? *
Should be Empty:

Payment

Credit Card