COVID-19 Testing Scheduling and Consent Form - CPESN Pharmacy
Select a 15-minute time slot for your COVID-19 Testing Appointment
Submitter Name
Please Select
Andrew Brown
Cody Clifton
Brandy Seignemartin
Kari VanderHouwen
Submitted Date
-
Month
-
Day
Year
Date
Facility Name
Please Select
[insert pharmacy name]
Facility License Number
Please Select
[insert clia waiver number]
Facility Address
Please Select
[insert pharmacy address]
Facility State
Please Select
[insert state]
Facility Zip Code
Please Select
[insert]
Facility County
Please Select
[insert]
Facility Phone
Please Select
[insert]
Type of Facility
Please Select
Pharmacy
Other facility type specify
Please Select
Ordering Provider Name
Please Select
[Insert options]
[Insert options]
Ordering Provider Phone
Please Select
[insert]
NPI
Please Select
[insert pharmacist NPI]
[insert pharmacist NPI]
Ordering Provider Address
Please Select
[insert pharmacy address]
Ordering Provider City
Please Select
[insert]
Ordering Provider Zip Code
Please Select
[insert pharmacist info/probably the pharmacy's info]
Ordering Provider County
Please Select
[insert pharmacist info/probably the pharmacy's info]
Patient Last Name
Patient First Name
Patient Middle Name/Initial
Sex at birth
Please Select
Female
Male
Neither/Other
Unknown
Date of Birth
-
Month
-
Day
Year
Date
Age in Years
Please Select
1
2
3
4
5
6
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10
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102
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105
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109
110
Affiliation to Facility
*
Please Select
Patient
Patient Street Address
Patient City
Patient State
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
You may choose a different option if your State is different
Patient Zip Code
Patient County of Residence
Please Select
Adams
Asotin
Benton
Chelan
Clallam
Clark
Columbia
Cowlitz
Douglas
Ferry
Franklin
Garfield
Grant
Grays Harbor
Island
Jefferson
King
Kitsap
Kittitas
Klickitat
Lewis
Lincoln
Mason
Okanogan
Pacific
Pend Oreille
Pierce
San Juan
Skagit
Skamania
Snohomish
Spokane
Stevens
Thurston
Wahkiakum
Walla Walla
Whatcom
Whitman
Yakima
You may choose a different option if your County is different [note to other state's beside WA: insert counties in alpha order by googling a list]
Patient Phone Number
Please enter a valid phone number.
Is patient pregnant?
Please Select
Yes
No
Unknown
Did patient have symptoms of COVID-19 at time of testing?
Please Select
Yes
No
Did the patient die?
Please Select
Yes
No
Unkown
Date of Death (If Applicable)
-
Month
-
Day
Year
Date
Patient Race
Please Select
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Pacific Islander
White
Other
Unknown
Specify other race
Patient Ethnicity
Please Select
Hispanic or Latino
Not Hispanic or Latino
Unknown
Signature of Patient or Guardian**
Patient Identifier
get from the sticker (goes with specimen ID too)
Patient Identifier Type
Please Select
Medical Record Number
Specimen Identifier
Patient Internal ID
Patient External ID
Public Health ID
Specify other patient identifier
Test Name
Please Select
BD Veritor System for Rapid Detection of SARS-CoV-2
Lot & Expiration Date**
Please Select
[insert all lot & expiration numbers]
[insert all lot & expiration numbers]
**Not reported to WA State; select the default one until you run out of tests; then delete and select another
Specify other test name
Specimen Type
Please Select
Nasal Swab
NP (nasopharyngeal swab)
Test Results
Please Select
Detected/Positive
Not detected/Negative
Inconclusive/Undetermined/Invalid/Equivocal
Specimen Collection Date
-
Month
-
Day
Year
Date
Device Identifier
Above is specific to BD Veritor COVID19 Test; Access others that are available on this website: https://www.fda.gov/medical-devices/device-advice-comprehensive-regulatory-assistance/unique-device-identification-system-udi-system
Specimen ID
This is the full 8 digit data (12032020) and the patient identifier # (1) on the sticker. Input should look like 120320201 [specific to Duvall Family Drugs; you can make your own if your state requires this]
Submit
Should be Empty: