Name
Date of Birth
/
Month
/
Day
Year
Date
Age
Legal Guardian Name
Email
example@example.com
Address
Address
City
State
Zip
County
Primary Care Provider
Medication Allergies
Current Medications (Rx, OTC, herbal, topical, pain or allergy, supplements, vitamins, etc.)
Treatments tried for current condition (if none, indicate N/A)
Are you 6 years of age or older?
Yes
No
Are you experiencing any altered mental status or change from normal cognition?
Yes
No
If you answered "yes" to the above, please explain:
Have you ever been diagnosed with a weakened immune system (e.g. cancer, HIV/AIDS, transplant, long term steroids, etc?
Yes
No
If you answered "yes" to the above, please explain:
Do you have a history of rheumatic fever, rheumatic heart disease, scarlet fever, or acute GAS pharyngitis induced glomerulonephritis?
Yes
No
If you answered "yes" to the above, please explain:
Do you have a history of allergic reactions to antibiotics, such as penicillin, amoxycillin, cephalexin, clarithromycin, or clindamycin?
Yes
No
Are you a resident of a nursing home or long-term care facility, in hospice, or receiving home health services?
Yes
No
Do you have a pending test for your symptoms (COVID, strep, flu)?
Yes
No
Have you had a tonsillectomy in the previous 30 days?
Yes
No
Are you receiving hemodialysis?
Yes
No
Do you have a history of chronic kidney disease or reduced kidney function?
Yes
No
When did your symptoms start?
More than 4 days ago
Less than 4 days ago
Do you have any of the following symptoms (check all that apply)?
Fever
Sore Throat
Pain Swallowing
Swollen/tender lymph nodes
Inflamed/Swollen tonsils or uvula
Other
Other
Please answer the following to help our pharmacists assess your eligibility for an acute Group A Strep Pharyngitis test. Note: All eligible patients will be evaluated by a pharmacist in store. The $65 fee will cover the assessment by the pharmacist. Test will be included if appropriate.
Thank you! After clicking "submit" you should receive a call from us in about an hour. The pharmacist will need to review the form prior to scheduling the appointment. Thanks so much!
Preview PDF
Submit
Are you Pregnant or Breastfeeding?
Yes
No
Should be Empty: