Cognitive Function Testing Appointment

COGNITIVE FUNCTION TESTING FORM

Please fill out this form to schedule your Cognitive Function Test at Skippack Pharmacy. Your appointment is not held until you complete your registration successfully and receive a GREEN CHECK MARK at the end. In order to guarantee your spot, do not navigate away from this page until you've submitted the form.
Skippack Pharmacy is excited to offer Cognivue Thrive, a computer-based test that efficiently evaluates your cognitive function while being simple to use. This FDA-cleared technology has been used by healthcare providers for years to test for cognitive function and screen for cognitive decline. This form of cognitive testing uses a personalized, consistent, and reliable assessment of your overall cognitive function. It establishes a baseline score that you and your healthcare provider can use to monitor changes as they develop and implement interventions when necessary. Repeat tests can measure the success of interventions put in place. The best part is that it only takes 15 minutes and can be done on a self-administered basis, making it easy and convenient for you!

Cognivue Thrive evaluates three cognitive domains: memory, visuospatial, and executive function. It also measures two speed performance parameters: reaction time and speed processing. These are essential areas for overall cognitive performance at any age.

Cognivue Thrive is meant to help evaluate your cognitive function as an additional tool. It is not a stand-alone diagnostic tool, which means that clinical review is necessary for an accurate interpretation. For a better understanding of your results, please contact your healthcare provider.

If you have any questions about Cognivue Thrive or want to learn more about how it can potentially help evaluate your cognitive function, please visit www.cognivue.com

PATIENT INFORMATION

Please provide your personal information below so that we can accurately identify you and confirm your appointment for the Cognivue Thrive: Cognitive Function Testing. After the test, we will happily send you an email with your test results, but this is completely optional and your choice. Your privacy is important to us, and all information provided will be kept confidential.
First Name*
Last Name*
Date of Birth*

MonthDayYear
Patients must be at least 12 years or older.
Sex*

MaleFemaleNot Specified
Email Address*

Confirmation EmailPlease double check and ensure this is accurate otherwise an email will be sent to the incorrect email address. Your email will only be used to send you a confirmation/reminder unless you indicate in the next question that you would like your test results emailed to you as well.
After your test is completed, would you prefer to receive your results via email and a paper copy, or just a paper copy? If you choose not to receive them via email, you will still receive a paper copy of your test results.*

Both via email and a paper copyOnly a paper copy
Address*

Address Line 1

Address Line 2 (PO Box, Unit #, or Suite #)

CityState / Province

Postal / Zip Code
Phone Number*
We will use this number to contact you in case you are running late for your appointment or if we need to reach you for any other urgent matter.

SCHEDULE YOUR APPOINTMENT

Please select a preferred date and time for your appointment for the Cognivue Thrive: Cognitive Function Testing. Our wellness clinic is open Monday through Friday from 10AM-6PM. Note, this is different from our pharmacy hours of operation. Please be sure to arrive on time for your appointment!
Schedule an Appointment*
CONSENT & AUTHORIZATION

We kindly ask that you take a few moments to carefully read and consider the following section. This section outlines important information regarding your participation in the Cognivue Thrive: Cognitive Function Testing.
I voluntarily consent and authorize Skippack Pharmacy to conduct a Cognivue Thrive: Cognitive Function Testing for myself and understand that my test results will only be analyzed and discussed with me only upon my explicit permission. I am aware that this test does not diagnose any medical condition, but rather provides information about my cognitive function. I am aware I should consult with my healthcare provider to discuss my results and develop a plan for any necessary follow-up testing or treatment. I am aware I should not make any medical decisions based solely on the results of this test. I understand that this testing is not intended to replace professional medical advice, diagnosis, or treatment. I understand that the type of test I am signing up for is the Cognivue Thrive: Cognitive Function Testing. To the fullest extent permitted by law, I hereby release, discharge, and hold harmless, Skippack Pharmacy, without limitation, any of their respective partners, officers, directors, employees, representatives, and agents from any and all claims, liability, and damages, of whatever kind or nature, arising out of or in connection with any act or omission relating to my Cognivue Thrive: Cognitive Function Testing. I understand and agree that I will receive a physical copy of my test results, and that I may also choose to receive a copy of my test results by email.
Consent & Authorization*

By checking this box and signing electronically below, I agree to the following statements: I have fully read, understand, and agree to the statement above.
Signature*

Clear
Date of Signature*

MonthDayYear

PAYMENT

The cost of the Cognivue Thrive: Cognitive Function Testing is $49.99 per test. This test is not covered by prescription insurance; you may attempt to submit it to your medical insurance; however, we cannot assume responsibility if they do not cover it thereafter. Patients are responsible for the cost of the test up front. This is NOT a hold on your credit card, by inputting your credit card number below, you will be charged for the test immediately.
How are you paying for the test?

CREDIT CARD - I will provide my credit card information below and be charged $49.99. On a rare instance, you may enter your card information & the appointment will be confirmed but our payment processor, Square, will not charge your credit card. If this happens, we'll ask you for your card information again at check-in & we assure you that will not be double charged. Click the checkbox next to "Cognivue Thrive: Cognitive Function & Brain Health Testing" below AND input your credit card information.CASH - I will pay cash in person and bring $49.99 for the Cognivue Thrive: Cognitive Function Testing. You DO NOT have to click any of the options below and DO NOT enter your credit card information.

Check the box below ONLY if you are paying via credit card. If you are paying via cash, DO NOT CHECK THE BOX BELOW.

Cognivue Thrive: Cognitive Function Testing

$49.99 Quantity

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Total

$0.00

Payment Methods

Credit Card

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If you do not see a green checkmark on the next page or get an error, your submission did not go through and your appointment is not confirmed. Unfortunately, you will have to fill out another appointment form. Please keep an eye out in your provided email and check your spam email as well from clinic@skippackpharmacy.com. By checking this box, you also acknowledge this test is non-refundable and that IF you entered your credit card information and hit submit BUT the credit card does not get processed, you will provide the card information again at check-in (you will not be double charged). If you agree, please click on the box on the left and then hit submit below.
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COGNITIVE FUNCTION TESTING FORM

PATIENT INFORMATION

SCHEDULE YOUR APPOINTMENT

CONSENT & AUTHORIZATION

PAYMENT

Payment Methods