HAZLET PHARMACY POCT RAPID Covid Antigen Testing

Rapid Testing for COVID19

Cost is $65

Patient Intake and Assessment Form

2874 Highway 35 Hazlet, NJ 07730
Please choose an appointment Date and Time:*
Patient Name*
Gender*

MaleFemale
Birth Date*

MonthDayYear
Address*

Patient Address

Street Address Line 2

City/State/ZipState / Province

Postal / Zip Code
Patient Phone Number*
Format: (000) 000-0000.
Patient Weight
Primary Care Physician
Physician Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Physician Address
Medication Allergies
Current Medications
Past Medical History
Current Situation When did your symptoms start?
Date exposed to COVID 19 (if known)?

MonthDayYear
Date
Which of these symptoms do you currently have?
Fever?*

YesNo
What temperature?
Cough?*

YesNo
Vomiting?*

YesNo
Diarrhea?*

YesNo
Shortness of Breath?*

YesNo
Chills?*

YesNo
Sore Throat?*

YesNo
Muscle Pain?*

YesNo
New loss of Taste or Smell?*

YesNo
Have you taken any medications for these symptoms?*

YesNo
If yes, what have you taken, and when?
Do you have any of the following medical conditions?

Asthma or Chronic Lung DiseaseSerious Heart Condition, such as Congestive Heart FailureDiseases or conditions that make it harder to coughKidney Failure or End Stage Renal DiseaseConditions that result in a weakened immune system, including Cancer treatmentsDiabetesPregnancyExtreme ObesityCirrhosis
Have you been prioritized by your local health department for testing?*

YesNo
Are you a health care worker, first responder, or law enforcement officer?*

YesNo
Do you live or work in a treatment facility, group home, or other group setting?*

YesNo
Are you a caregiver for an elderly person or someone with a weakened immune system?*

YesNo
Date/Time

MonthDayYear
Date
Hour MinutesAM/PM Option
Should be Empty: