Point of Care Testing Form

2521 13th Street, Suite A

St Cloud, FL 34769

407-892-7166

www.unlimitedrx.com
503 E 1st Street

Sanford, FL 32771

407-323-6413

www.unlimitedrx.com
Point of Care Testing Form and Screening

NOTE: We are unable to bill for insurance for these tests at this time. We will produce results on site and provide report for documentation. There are no refunds, however if the test is inconclusive we will retest at no charge.
SDOC Employees ONLY

The copay for SDOC employees enrolled in health plan is $15.00. Bring your insurance card and identification to the appointment.
Select Test Request

Influenza A+B / SARS-COV2 - TEST & ASSESSMENT - $75.00Strep A - TEST & ASSESSMENT - $75.00TEST & TREAT FULL WORK-UP (STREP, FLU AND SARS-COV) - $100.00
Patient Name*

First NameLast Name
Date of Birth*

MonthDayYear
Gender*

MaleFemale
Race*
Ethnicity*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Caregiver Name (if different from patient)

First NameLast Name
Cell Phone Number (For call/text when results ready)*
Please enter a valid phone number.
Email (for test results via email)*
example@example.com
Appointment*
Select Location*

Saint CloudSanford (Tru-Valu Drugs)
Select Service*

Test OnlyTest and Consultation with Pharmacist

Results

Sample ID
Collection Date

MonthDayYear
Date
Collection Time
Read Time
Medications

All medications will have 0 refills per the protocol
Covid-19
Nirmatrelvir/Ritonavir (Paxlovid EUA)
Drug
Dosing
Quantity
Influenza
Oseltamivir (Tamiflu)
Drug
Dosing
Directions
Days Supply
Quantity
Baloxavir (Xofluza)
Drug
Directions
Quantity
Group A Strep
Penicillin VK
Drug
Dose
Directions
Days Supply
Quantity
Amoxicillin
Drug
Dose
Directions
Days Supply
Quantity
Patients with Penicillin Allergy
Cephalexin
Drug
Dose
Directions
Days Supply
Quantity
Clindamycin
Drug
Dose
Directions
Days Supply
Quantity
Azithromycin
Drug
Dose
Directions
Days Supply
Quantity
Supportive Care
Benzonatate

Do not use in children under 10 years old
Drug
Directions
Quantity
Promethazine/Dextromethorphan Oral Solution
Drug
Directions
Quantity
Methylprednisolone Dose Pak
Drug
Directions
Quantity
Ipratropium nasal solution
Drug
Directions
Quantity
Albuterol Inhaler

200 puffs per inhaler
Drug
Directions
Quantity
Brompheniramine/Pseudoephedrine HCl/Dextromethorphan
Drug
Directions
Quantity
Pharmacist

Select your name and sign below
Pharmacist
By signing below, I attest that I have evaluated the patient and the results of their Point-of-Care test and have determined this therapy or lack-of therapy to be appropriate based on the protocol.
Signature

Clear
Date

MonthDayYear
Date
Should be Empty:

Health Screening Questions