Name
Date of Birth
/
Month
/
Day
Year
Date
Age
Email
example@example.com
Address
Address
City
State
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)
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.
Are you 18 years of age or older?
Yes
No
Are you pregnant or breastfeeding?
Yes
No
Have you ever been diagnosed with a weakened immune system (e.g. cancer, HIV/AIDS, transjplant, long-term steroids?
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
Do you have a history of allergic reactions to antibiotics, such as penicillin, amoxicillin, 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
When did your symptoms start?
More than 4 days ago
Fewer 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 in the neck region
Inflamed or swollen tonsils or uvula
Other (please explain below)
If you answered "other" above, please explain:
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!
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