COVID19 Testing Patient Form

IMPORTANT: THIS FORM MUST BE COMPLETED PRIOR TO TESTING for EACH person being tested.

PLEASE READ:

Completing this form is Step 1 of the COVID-19 testing process. Upon completion, you will receive a link via e-mail to book your appointment.

Antibody testing is $64

PCR Oral Swab testing is $175

Antigen Rapid Testing is $95

You must submit separate forms for EACH individual person to be tested including children and dependents.

If you have any questions, please contact us at 305-982-8727 or at info@ethoswellnesspharmacy.com.

What type of test are you requesting? *

Antibody Test PCR Oral Swab Test (this is the type needed for travel) Antigen Rapid Test (via nasal swab)

Which test do you need?

Antibody Test: For patients who feel they may have been exposed to Coronavirus 12 or more days ago. Fingerprick test, results in 15 minutes.

PCR Oral Swab Test: To test whether patient is actively infected. This is the test you need for travel documentation. Throat swab. Results take 36-48 hours.

Antigen Rapid Testing: To test for active infection if currently experiencing symptoms. Nasal swab, results in 15 minutes. Cannot be used for travel documentation.

PATIENT NAME *

First Name Middle Name Last Name

If testing for TRAVEL documentation, the name on this form MUST MATCH PATIENT'S NAME EXACTLY AS WRITTEN IN THEIR PASSPORT. We will not be able to change it afterward. *

I understand the above N/A: I am not travelling

GUARDIAN NAME (if patient under 18)

First Name Last Name

PHONE *

Phone Number

E-MAIL *

example@example.com

ADDRESS *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

PATIENT DATE OF BIRTH *

Month Day Year

PATIENT BIOLOGICAL SEX

Female Male

PATIENT PRIMARY CARE DOCTOR

Primary Physician Name

PRIMARY CARE DOCTOR'S PHONE

Doctor's Phone Number

Does patient have any of the following conditions? (select all that apply) *

Hypertension / High Blood Pressure Diabetes COPD or other lung/respiratory condition Heart failure / Cardiovascular issues Kidney Disease None of the above conditions

Do you suspect you (patient) may have COVID-19 right now?

Yes, I am currently experiencing symptoms Not currently but I had symptoms within the last month No, I don't think so

Has patient experienced any of the following symptoms? *

Yes, within the last 14 days

Yes, within the last 3 days

Currently experiencing this symptom

No, I have not had this symptom

Fever

Cough

Body Ache / Joint or Muscle Pain

Shortness of breath

Loss of smell or taste

Chest pain or discomfort

Vomit or diarrhea

Sore Throat

Fatigue

Chills

In the last 14 days has the patient... *

Yes

No

If yes, provide date

been diagnosed with COVID-19?

been within proximity of someone who has received a confirmed diagnosis of COVID-19?

been within proximity of someone who was/is symptomatic but undiagnosed?

attended an event with more than 10 people ?

Any additional comments you wish to share with the pharmacist:

Notes

I understand that testing will be done by appointment only.

I understand that the Pharmacist will screen each patient to determine testing needs and retains the right to refer patient to another testing facility or healthcare provider.

As it pertains to antibdoy testing: In compliance with the US FDA Policy for Diagnostic Tests for Coronavirus Disease-2019 during the Public Health Emergency dated March 16, 2020 that describes the regulations for the development and US distribution of serology tests for the detection of antibodies to SARS-CoV-2, any test reports resulting from the use of the HEALGEN Profile 2019-nCoV IgG/IgM Test Card for whole blood, serum, or plasma must bear the following information:

• This test has not been reviewed by the FDA.
• Negative results do not rule out SARS-CoV-2 infection, particularly in those who have been in
contact with the virus. Follow-up testing with a molecular diagnostic should be considered to rule
out infection in these individuals.
• Results from antibody testing should not be used as the sole basis to diagnose or exclude SARS-CoV2 infection or to inform infection status.
• Positive results may be due to past or present infection with non-SARS-CoV-2 coronavirus strains,
such as coronavirus HKU1, NL63, OC43, or 229E.
• Not for the screening of donated blood.

I have read and agree to the terms above. *

Yes

PATIENT SCREENING FORM