• Condo Pharmacy COVID-19 Testing Screening and Consent Form

  • Format: (000) 000-0000.
  • Date of Birth*
     / /
  • Pregnant or Post Partum
  • Race (Check all that apply)
  • Ethnicity

  • Employer Information or School Information (if Student)

  • Format: (000) 000-0000.

  • Screening

  • Are you experiencing any of the following?*
  • Onset of symptoms
     - -
  • Within the past 14 days, have you had contact with anyone who has COVID-19 or COVID-like symptoms?*
  • In the past 14 days, have you been on a commercial flight or traveled outside of the United States?*
  • In the past 14 days, have you been in close proximity to anyone who has been on a commercial flight or traveled outside of the United States?*
  • Is this your first test for COVID-19?*
  • Date of test
     / /

  • Consent

  • I authorize the collection and testing for COVID-19 through an oropharyngeal (throat), nasal, and/or nasopharyngeal swab, as ordered by an authorized medical provider/public health official.*
  • I understand that I will be informed of my test results by the ordering provider or their designee.*
  • By voluntarily agreeing to this testing, I understand that my test results will be disclosed to the county, state, or any other government entity as may be required and/or permitted by law, and that my test results will be reported to the operator of my facility.*
  • I acknowledge that a positive test result means I must self-isolate in an effort to avoid infecting others.*
  • I understand that Condo Pharmacy employees, volunteers, and contractors, who are collecting specimens and providing test results. This specimen collection and testing does not replace treatment by my medical provider. I assume complete and full responsibility to take appropriate action with regard to my test results. I agree I will seek medical advice, care, and treatment from my medical provider if I have questions or concerns, or if my condition worsens.*
  • I understand that possible discomfort or other complications, such as the potential for a bloody nose, can happen during sample collection.*
  • I understand that, as with any medical test, there is the potential for false positive or false negative test results.*

  • I, the undersigned, have been informed about the test purposes, possible benefits and risks, and I acknowledge that I may request a copy of this informed consent. I understand that I may ask questions at any time and I voluntarily agree to testing for COVID-19. 

  • Clear
  • Today's Date*
     / /

  • Insurance Information

  • COVID-19 testing is not covered for population health purposes such as testing and screening of asymptomatic individuals for travel, return to work , or return to school.

  • Bill Insurance?*
  • Format: (000) 000-0000.

  • Failure to accurately provide all of the requested information will delay your appointment and may cause it to be rescheduled. Please call us with questions BEFORE submitting this form.

  • Should be Empty:
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