COVID, Flu, and/or Strep Test Consent JotForm

Disclaimer: Please note that if you have selected YES to any of the following below, have vitals that are abnormal at the time of appointemnt or can not provide updated kidney function lab results, we will only be able to test you. We unfortuanetly will not be able to treat you but are happy to refer you to the closet urgent care.

Under the age of 18Immunocompromised state (i.e: cancer that developed in the blood, bone marrow or lymph node; HIV/AIDS; immunosuppressant therapy)Have had a positive influenza test within the past monthHave a medical condition requiring supplemental oxygen therapyHypersensitivity to antiviral treatment for influenza (oseltamivir) or any similiar productHave been administered FluMist (Nasal spray Influenza Vaccine) within the past 2 weeksHave been receiving hospice or home health servicesHave taken an antiviral in the last 30 daysHave a pending influenza test at another pharmacy, laboratory, medical care facility or clinic.History of rheumatic fever, rheumatic heart disease, kidney inflammation, throat inflammationHave viral features such as infected eyes, runny nose, cough, oral ulcer and/or hoarsenessHypersensitivity to antibiotic therapy for treatment of strep throat (penicillin, cephalosporin, clindamycin or azithromycin)History of tonsil removal in the past 30 daysHave taken an antibiotic for sore throat in the past 30 daysHave taken an antiviral for sore throat or upper respiratory in the past 30 daysHas a pending strep test at another pharmacy, laboratory, medical care facility or clinic.has severe respiratory distress inclusive of : Muffled voice, Drooling, Abnormal breathing, Respiratory stress, “Sniffing” or “tripod” positions, Severe sore throat lasting >7 days, Muscle spasm in your cheek, crunching sound when moving jaw, Stiff neck, History of trauma to throatNone of These Apply

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No symptomsMild symptoms (barely noticeable)Moderate symptoms (interferes with daily activities)Severe symptoms (unable to carry out daily activities)Very severe symptoms (unable to carry out daily activities)

InfluenzaCOVID-19Strep

By signing below, you agree that you have completed the patient history form to your best knowledge and understand that you have the right to refuse the recommended treatment options. you consent to, or give consent for, the administration of the testing for influenza, COVID, and/or Strep A.