AstisRx COVID-19 Test Request

Asti's Pharmacy COVID Test Request Form

Please complete the form below to request and schedule your test. IMPORTANT: When you arrive to the pharmacy for your appointment for rapid antigen testing, please REMAIN in your vehicle and call the pharmacy at 412-512-4850 and one of our team members will come service you curbside. THANK YOU
Patient Name*

First NameLast Name
Patient Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Patient Date of Birth*

MonthDayYear
Age
BE ADVISED

Children under the age of 15 are only eligible for a Rapid PCR Test (limited availability).

Rapid Antigen Tests have a minimum age of 15 years old.
Email*
example@example.com
Gender*
Primary Care Physician*
Are you a current prescription customer at Asti's Pharmacy?*
List Your Medication Allergies (if no allergies, type "n/a")*
Current Medications*
Please Select Any of the Following that are TRUE:

History of Lung CancerRecent PneumoniaRecent Hospitalization (less than 30 days)Severe Lung DiseaseCurrent SmokerRecently Diagnosed with the FluRecently Diagnosed with Strep Throat
Other Relevant Medical History*
Why are you requesting a COVID Test?*
When did your symptoms start for your current illness?*

MonthDayYear
Date symptoms began?
Which of the following symptoms are you currently experiencing? (select all that apply)*

FeverRecent Loss of Smell/TasteHeadacheMuscle PainSore ThroatRunny NoseCoughFatigueHead/Nasal CongestionI have no symptomsOther
What was/is your temperature?*
What other symptoms are you experiencing?*
Have you taken any medications for these symptoms?*
What medication(s) have you taken?*
Did you receive the Flu Vaccine this year?*

COVID Test Selection*

COVID-19 ANTIBODY TestThis is a finger-prick blood test to test for the presence of ANTIBODIES for SARSCoV2 (COVID-19) virus. This will NOT test for active infection.

$50.00

COVID-19 Rapid ANTIGEN TestThis a nasal-swab test to check for ACTIVE INFECTION of COVID-19.

$75.00

COVID-19 Rapid PCR TestThis is a nasal PCR test with results within 30 minutes. This test meets Travel Testing Requirements.

$165.00

Printed Test ResultIf you would like to have a signed document attesting your results.

$10.00

Enter coupon

Total

$0.00

Pharmacy Use Only
Non-PCR Test Scheduler*
PCR Test Scheduler*
IMPORTANT

When you arrive for your test, please STAY IN YOUR VEHICLE and call 412-512-4850 to notify the staff that you have arrived. Please share your vehicle make and model, as well as where you are parked.

A staff member will come out to your vehicle to test you in the parking lot. They will also request a form of payment, so please be prepared.

Thank you!
Today's Date

MonthDayYear
Date
Should be Empty:

Asti's Pharmacy COVID Test Request Form