Click HERE to book an appointment before filling out this form, or call us for appointment setup assistance. This test may be paid by:
COVID-19 Uninsured program
By cash for $120
*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
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.