COVID-19 Rapid Antigen/PCR Test Form

Please correct the errors described below.

Click HERE to book an appointment before filling out this form, or call us for appointment setup assistance. This test may be paid by:

  1. Your Insurance
  2. COVID-19 Uninsured program
  3. By cash

*If paying with card, have card ready to present for payment processing.

Answer The Following Assessment

Example: recent travel (please include location), contact with another lab-confirmed COVID-19 case, clearance for surgery, return to work, etc.)

Pre-Existing Medical Conditions

(asthma/emphysema/COPD)
(neurodevelopmental/intellectual disabilty)

Consent Form

I authorize rxAssist Pharmacy to conduct collection and testing for rapid COVID-19 antigen test. I authorize my test results to be disclosed to the county, state, or to any other governmental entity as may be required by law. I understand that I am not creating a patient provider relationship with rxAssist Pharmacy by participating in testing. I understand that rxAssist Pharmacy is not acting as my medical provider. I assume complete and full responsibility to take appropriate action with regard to my test results. I acknowledge that I have been given a copy of rxAssist Pharmacy Notice of Privacy Practices. I have been informed about the test purpose, procedures, possible benefits, and risks. I acknowledge that I have read, understand, agree, certify and/or authorize the information above and further agree to hold harmless rxAssist Pharmacy, including its employees, agents, and contractors from all liability and claims. And |have also read the facts sheets on COVID-19.

COVID-19 FACTS SHEET
rxAssist Pharmacy Privacy Policy

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Bacgkround

Your information will be encrypted.

Loading...