Harvey N-Strep Adults

Name
Date of Birth

MonthDayYear
Date
Age
Email
example@example.com
Address
Format: (000) 000-0000.
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?

YesNo
Are you pregnant or breastfeeding?

YesNo
Have you ever been diagnosed with a weakened immune system (e.g. cancer, HIV/AIDS, transjplant, long-term steroids?

YesNo
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?

YesNo
Do you have a history of allergic reactions to antibiotics, such as penicillin, amoxicillin, cephalexin, clarithromycin or clindamycin?

YesNo
Are you a resident of a nursing home or long-term care facility, in hospice or receiving home health services?

YesNo
Do you have a pending test for your symptoms (COVID, strep, flu)?

YesNo
Have you had a tonsillectomy in the previous 30 days?

YesNo
When did your symptoms start?

More than 4 days agoFewer than 4 days ago
Do you have any of the following symptoms(check all that apply)?

FeverSore throatPain SwallowingSwollen/tender lymph nodes in the neck regionInflamed or swollen tonsils or uvulaOther (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!
Zip
Should be Empty:

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!