POC COVID/FLU/STREP

POINT OF CARE TESTING for

COVID - FLU A/B - STREP

Patient Intake and Assessment Form

515 Inman Avenue, Colonia, NJ 07067
Patient Name*
Gender*

MaleFemale
Birth Date*

MonthDayYear
Address*

Patient Address

Street Address Line 2

City/State/ZipState / Province

Postal / Zip Code
Patient Phone Number*
Primary Care Physician
Medication Allergies
Current Medications
Which of these symptoms do you currently have?
Fever?*

YesNo
What temperature?
Cough?*

YesNo
Vomiting?*

YesNo
Diarrhea?*

YesNo
Shortness of Breath?*

YesNo
Chills?*

YesNo
Sore Throat?*

YesNo
Muscle Pain?*

YesNo
New loss of Taste or Smell?*

YesNo
Have you taken any medications for these symptoms?*

YesNo
Email
example@example.com
My Products
prevnext( X )
COVID & FLU COMBO swab
$35.00 Quantity

STREP swab
$10.00 Quantity

Total

$0.00
For faster service please pay online above OR you can pay in store for a cash discount.

Payments must be made before testing.

Here for you always,

You COLONIA PHARMACY FAMILY
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