RAPID ANTIGEN COVID-19 Patient Screening Form ($75)

RAPID ANTIGEN COVID-19 TEST ($75)

Please contact your selected pharmacy location to check for availability and testing hours before submitting this form. (Xin quý vị vui lòng gọi cho tiệm thuốc để biết giờ xét nghiệm trước khi điền đơn)
Select one location: *

MTM Pharmacy - 12666 Brookhurst St, Ste 110, Garden Grove, CA 92840 P: (714) 705-6992 MTM Phamacy Bolsa Medical - 6552 Bolsa Ave, Ste A, Huntington Beach, CA 92647 P: (714) 916-5383 MTM Phamacy Caremore Anaheim - 1172 N Euclid St, Anaheim, CA 92801 P: (714) 613-1971
Diagnostic Testing & Screening Form
Patient name (print First Name & Last Name) *
tên và họ
Date of Birth (Month/Date/Year) *
tháng/ngày/năm sinh
Address: *
Địa chỉ
Phone Number: *
Số Điện Thoại
Email Address:
Age *
Tuổi
Weight
Race/Ethnicity: *
chủng tộc
Date of testing *

Month Day Year
Ngày xét Nghiệm
Name of Patient Assessor (To Be Filled Out By Staff Only)
Tên của Dược Sĩ
PATIENT SYMPTOMS

Symptoms may appear 2-14 days after exposure to the virus. People with these symptoms may have COVID-19:

Nếu quý vị có những triệu chứng sau, xin điền vào dứới đây
Check all that apply:

Fever or chills (Sốt) New loss of taste or smell (Không nếm/ngửi được mùi vị) Cough (Ho) Shortness of breath or difficulty breathing (Khó thở/thở dốc) Fatigue (Mệt Mỏi) Muscle or Body Aches (Đau Nhức) Sore throat (Đau Họng) Nausea or Vomitting (Ói Mửa) Congestion or runny nose (Nghẹt/ Chảy Mũi) Diarrhea (Tiêu Chảy) Headache (Nhức Đầu)
Symptoms started (how many days or hours ago)
triệu chứng bắt đầu khi nào
Risk Level:

Low High (If high, please select reasons below)
Reasons for High Risk
Patient Check All That Apply:

Over 65 Heart Condition Cancer Immunocompromised Chronic Kidney Disease Obesity COPD Sickle Cell Disease Type 2 Diabetes Smoker
COVID TEST RESULTS:
(To Be Filled Out By Pharmacist Only)

Negative Positive
Date recorded (to be filled out by pharmacy staff):

Month Day Year
Date
Recorded by (to be filled out by pharmacist only):
**Important, Please Read**

Notes to our Clients and Patients:

Please go to the MTM Pharmacy Location that you have contacted to receive your test. Testing are provided based on First Come First Serve Basis. Antigen Tests are $75 per test per person. Results are available in 15-20 minutes. We highly recommend using the section below to make the payment online.

Please note that antigen tests has a 98%-100% specificity, which means the false positive rate is less than 2% of all the tests performed. Another PCR test is highly recommended to confirm the result.

When you arrive at the testing sites, please DO NOT enter the pharmacy. Please park and wait in your car, then call the phone number of that pharmacy location and provide staff with your car information (color, make, last 3 digit of your license plate, parking location). Payments will be required before the procedure is performed. If You would like to pay in person instead of paying online, please give payment to pharmacy staff upon arrival.

Khi quý vị đến nơi, xin đừng bước vào tiệm thuốc, xin đậu xe và gọi vào số điện thoại và cho nhân viên chúng tôi biết quý vị đang ngồi trong xe nào. Xin quý vị vui lòng thanh toán tiền $75 trước khi được xét nghiệm. Nếu quý vị muốn trả bằng tiền mặt, xin vui lòng gửi tiền cho nhân viên của chúng tôi khi đến nơi.

Check Here If You Would Like to Pay For The Test Online.

Rapid Antigen Covid-19 Onsite Test Please Check the "circle" on the top left corner of this Product if you are going to pay online. We encourage online payment to reduce contact between staff and patient as a safety precaution.

$ 75.00

Enter coupon

Total

$ 0.00

Credit Card
First Name	Last Name
Credit Card Number	Security Code
Expiration Month	Expiration Year
Billing Address
Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Should be Empty:

RAPID ANTIGEN COVID-19 TEST ($75)

Diagnostic Testing & Screening Form

Reasons for High Risk