FAR HILLS COVID 19 TESTING

Type of Test*

Telemedicine Consult with a Prescriber $35COMBO RAPID TEST (COVID, Flu, RSV, Strep - 30 mins) $100Rapid COVID Antigen Test ( Results in 30 minutes) $60Rapid RSV TEST (Results in 30 minutes) $60Rapid Flu Test (A/B) (Results in 30 Minutes) $60Rapid Strep Test (Results in 30 Minutes) $60Rapid Flu/COVID Antigen Test (Results in 30 minutes) $702-HOUR RT-PCR Test (Results in 2 hours, used for Travel & FAST result) $165Antibody Test (Results in 72 hours, with EXACT levels of IgG and IgM Antibodies) - includes a consult with dietitian $250
Test Result Sent
Result: Telemedicine Consult with a Prescriber
Test Appointment*
Name*

First NameLast Name
Birthdate*

MonthDayYear
Gender*

FemaleMaleOther
Cell Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Race*

African American or BlackAmerican Indian or Alaska NativeAsianNative Hawaiian or Other Pacific IslanderWhiteOtherDo Not Wish to Answer
Ethnicity

Hispanic or LatinoNot Hispanic or LatinoDo Not Wish to Answer
Are you symptomatic?*

YesNoUnknown
Insurance is required for FREE COVID Testing (as of 3/25/22)

YesNo
Insurance Card Front Photo (only required if booking free test)
Insurance Card Back Photo (only required if booking free test)
Social Security Number
if you do not have insurance , there will be a charge for COVID Test.
Refund Policy: There are no refunds for COVID testing once you confirm payment. You can reschedule to another date and time or we can offer you a free test voucher, should you miss your scheduled testing appointment.
I agree, To be fully financially responsible for the full cost of this COVID test(s) as listed above. I understand that any payment for which I am financially responsible for is due prior to the time of service, for which Far Hills Pharmacy will provide receipt of such invoice. There are no refunds once acknowledgment and payment information has been made. I agree to come in for testing and will not be issued any refunds for any reason whatsoever once I have agreed to these terms.

TOTAL COST

USDDescription

Credit Card

First Name

Last Name

Credit Card Number

Security Code

Expiration Month

Expiration Year

Billing Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

I voluntarily: Authorize and direct my healthcare provider of Far Hills Pharmacy to use or disclose my health information during the term of this authorization to any Physician, State or Federal Board or Agency, or Insurance Company, as required, for the purpose of treatment, payment, or other healthcare operation.
Further, I hereby given my consent: To the healthcare provider of Far Hills Pharmacy , as applicable (each an "applicable Provider"), to administer the COVID-19 test(s) I have requested above. I understand that it is not possible to predict all possible side effects or complications associated with receiving a COVID-19 test(s). I understand the risks and benefits associated with the above COVID-19 test(s) and have received, read, and/or had explained to me the information pertaining to the COVID test(s) I have selected and all of my questions have been answered by a Far Hills Pharmacy staff member to my satisfaction. On behalf of myself, my heirs and personal representatives, I hereby release and hold harmless the applicable Provider, its staff, agents, successors, divisions, affiliates, subsidiaries, officers, directors, contractors and employees from any and all liabilities or claims whether known or unknown arising out of, in connection with, or in any way related to the administration of the COVID test(s) listed above.
Date

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Date
Total Price (HIDDEN)
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