covidtest

COVID-19 Rapid Antigen Test

Insurance Currently Not Accepted

Cost of Test: $60
Appointment *
Patient Information
Full Name *

First Name Last Name
Date of Birth (Age 18+ Only) *

Month Day Year
Date
Gender *
Race/Ethnicity *
Required By CDC
Address *

Street Address

Street Address Line 2

City State

Zip Code
Home Phone Number *
Cell Phone Number (Optional)
Please enter a valid phone number.
Email *
example@example.com
Picture of Government Issued ID (Optional)

Drivers License, Passport, Etc
Cancel of
Clinical Information
Have you experienced any symptoms related to COVID-19? (Fever,Chills,Fever,Fatigue,Trouble Breathing,Headache,Loss of Smell/Taste) *

No Yes
If you answered yes to experiencing symptoms related to Covid-19, please select an estimate date when symptoms first occurred

Month Day Year
Date
Have you ever been hospitalized due to COVID-19? *

No Yes
Test Information (For Pharmacy Use Only)
Test Type
ICD-10 Code
Result

Positive Negative
Please Read Statements Below
This form is not intended to be used for the COVID-19 Vaccine. Please do not use this form to sign up for the COVID-19 Vaccine as it will prevent others from trying to sign up for COVID-19 testing. *

Acknowledged
Please submit below. Once you have hit submit, your appointment details will be confirmed and you will be redirected to our website that will contain instructions for your appointment on test day. Please check your email for confirmation of appointment. If you receive an email with confirmation we have received your submission. Please wait about 5-10 minutes after submitting to check email. Payment will be collected at the time of the appointment. We currently DO NOT ACCEPT INSURANCE and the cost of each test is $60.00. Please confirm by clicking the bubble you have read this statement and submit. *

I have read the following statement
Signature
Signature *

Clear
Terms & Conditions

The United States FDA has made this test available under an emergency access mechanism called an Emergency Use Authorization for the detection of SARS-CoV-2.• A negative result must be interpreted along with clinical observations, patient history and epidemiological information. • A negative result means that SARS-CoV-2 was not present in the specimen above the limit of • A positive result for COVID-19 indicates that SARS-CoV-2 was detected and the patient is presumptively infected with virus and presumed to be contagious. • Check with your end user to make sure they accept a Rapid Test. Rios Pharmacy is not responsible for any representations. I agree payment will be collected either before or after testing is completed.
Rios Pharmacy

35 South Morton Ave, Morton, PA 19070

Phone: (610) 543-1858

Fax: (610) 543-1862

Lab Director : Jonathan Dao

CLIA Number: 39D2205219
Should be Empty:

Patient Information

Clinical Information

Test Information (For Pharmacy Use Only)

Please Read Statements Below

Signature

Terms & Conditions