Respiratory testing

Consent for Services

Before providing your consent, be sure that you understand both the pros and cons of receiving treatment from a pharmacy provider. If you have any questions, we will be happy to discuss them with you. Do not sign your name on this form until you have read and understood each statement and the pharmacist has answered any questions that you may have. This information is confidential.

-I understand the benefits and risks of receiving treatment. 
-I have voluntarily chosen to receive care service from a pharmacy provider. I understand that Pharmacists can assess and treat some authorized conditions, and administer certain services including diagnostic testing, and vaccinations.
-I voluntarily assume full responsibility for any reactions or consequences that may result. 
-In the event of side effects, I understand I should call the pharmacy, my doctor, or 911. 
-I have had the opportunity to ask any questions I might have about the care and services provided to me by a pharmacy provider and the alternatives prior to my informed consent. I give consent to receive care services from the pharmacy provider, including any medications recommended or prescribed, or instructions from the pharmacy provider.
-I understand if the pharmacy provider cannot provide effective care, I may be referred to an appropriate care provider.
-I have read or have had read to me all of the above statements and understand them.

For the Point of Care Testing Program, I understand that:

- I authorize this point of care testing unit to conduct collection and testing through a nasal swab, throat swab, or saliva sample.
- I understand that information about my results (not including any identifying data) may be compiled by Scripted to establish local trends. This information may be shared with public health officials and community leaders. 
- I understand the testing unit is not acting as my medical provider, this testing does not replace treatment by my medical provider, and I assume complete and full responsibility to take appropriate action with regards to my test results. I agree I will seek medical advice, care and treatment from my medical provider if I have questions or concerns, or if my condition worsens. I understand that failure to seek medical treatment could result in serious injury or death.
- I understand that, as with any medical test, there is the potential for a false positive or false negative test result. 
- I understand and agree that I am financially responsible for all charges for any and all services rendered. This includes any medical service or visit, testing and any other screening ordered by the provider or staff. 
- I understand that while my insurance may confirm my benefits, confirmation of benefits is not a guarantee of payment and that I am responsible for any unpaid balance.
- I have been informed about the test purpose, procedures, possible benefits and risks, and I have received a copy of this Informed Consent.

Authorization to Request Treatment

I am requesting participation in receiving treatment for the pharmacist prescribed Upper Respiratory Testing program. I certify that the information provided regarding eligibility for the treatment is accurate and request that the treatment be given to me or to the person previously named for whom I am authorized to make this request. If I am signing on behalf of another individual (including a minor), I attest that I have the authority to do so.

I authorize the pharmacy providing services to release information to Medicare, Medicaid, or any other third party payer as needed and to request payment of authorized benefits to be made on my behalf to the pharmacy providing services, I certify that the information provided about my Medicare, Medicaid or other coverage is correct.

Disclosure of Records

I understand that the pharmacy providing services may be required to or may voluntarily disclose my health information with respect to this treatment to my healthcare providers, my insurance plan, health systems, hospitals, and/or state or federal registries. I understand that the pharmacy providing services will use and disclose my health information as set forth in the pharmacy privacy policy (a copy is available by request from the pharmacy team).

COVID / Flu / Strep Patient Assessment 

Before collecting any more health information, we want to emphasize that not all of our patients will be eligible for COVID/FLU/STREP treatment(s), but all patients will still be responsible for paying any applicable consultation and test administration fee.

Most people can get Upper Respiratory tests through Scripted, please take a look at the eligibility summaries below to see if you are a candidate for Scripted or if you should be seen by a doctor.

 

Patient may be eligible for COVID Treatment if:

- A Patient may be eligible for Influenza Treatment if:ge ≥18 years old with signs and symptoms of SARS-CoV-2 infection and confirmed active SARS-CoV-2 infection, as determined by a rapid antigen or PCR test
- The initial onset of COVID-19 signs/symptoms within 5 days

 

Patient may not be eligible for COVID Treatment if:

- > 5 days elapsed since the onset of symptoms
- Need for hospitalization for the medical treatment of COVID-19 (see Pharmacist Assessment)
- Females who are pregnant or breastfeeding
- History of hypersensitivity or other contraindication to any components of Paxlovid
- Knows medical history of active liver disease such as Hepatitis B or Hepatitis C
- History of significant kidney disease, receiving dialysis, or have known moderate to severe renal impairment
- Known HIV infection
- Suspected or confirmed concurrent active systemic infection other than COVID-19

 

Patient may be eligible for Influenza Treatment if:

- Positive influenza test or clinical suspicion of influenza infection
- Symptoms started less than 48 hours before presentation
- Any of the classical flu symptoms
   - Fever   
   - Myalgia
   - Headache
   - Malaise
   - Nonproductive cough
   - Sore throat
   - Rhinitis
- Age > 5 years

 

Patient may not be eligible for Influenza Treatment if:

- Clinical instability
- Age < 5 years
- Immunocompromised by medication or condition (cancer, HIV, steroids, etc.)
- Renal dysfunction (see medication specifics below)
- Pregnant/breastfeeding
- Long-term aspirin therapy if younger than 19
- Previous receipt of antiviral or an influenza medication in the last two weeks
- Home Oxygen use
- FluMist vaccination in the past two weeks

 

Patient may be eligible for Group A Strep (GAS) Treatment if:

- Age > 5 years
- Has signs or symptoms consistent with pharyngitis:
   - Sore throat
   - Painful swallowing
   - Fever
   - Headache
   - Tonsillitis/Uvulitis (erythema, edema, and/or exudates)
   - Enlarged and/or tender cervical lymph nodes

 

Patient may not be eligible for Group A Strep (GAS) Treatment if:

- Age < 5 years of age
- Pregnant or breastfeeding
- Renal dysfunction
- Symptoms of a viral infection (runny nose, cough, oral ulcers, nausea, vomiting, diarrhea, voice hoarseness)
- Signs of severe illness:
   - Altered mental status
   - Systolic hypotension - Tachypnea >20 breaths/min
   - Tachycardia >125 beats/min
   - Oxygenation - Body temperature >103F
- Unable to tolerate intake by mouth
- Allergies/intolerance to 1st and 2nd line therapy (Pencillins, Azithromycin, Clindamycin)
- History of rheumatic fever, post-streptococcal glomerulonephritis, post-streptococcal arthritis, or scarlet fever
- Symptoms of severe complications (rheumatic fever, tonsil abscess, glomerulonephritis)
- Previous GAS infection in the last 30 days
- Previous antibiotic administration within the last 30 days
- Hospitalization within 30 days
- Immunocompromised by medication or condition (cancer, steroids, HIV, asplenic, etc.)

If you choose to continue you will be asked to complete a self-assessment with questions that will be reviewed with you by a pharmacist during your consultation at the pharmacy. The pharmacist will refer to your responses to help make a safe, informed decision about appropriate care.

By signing below I agree to pay all applicable charges for respiratory testing and any medications that I choose to receive. I understand that if I cancel less than 24 hours prior to the appointment time I will not be refunded.