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
ROCKY POINT PAVILION PHARMACY
Facility License Number
Please Select
34D2182359
Facility Address
Please Select
7910 US HWY 117, SUITE 110
ROCKY POINT, NC 28457
Facility State
Please Select
NORTH CAROLINA
Facility Zip Code
Please Select
28457
Facility County
Please Select
PENDER
Facility Phone
Please Select
910-210-2030
Type of Facility
Please Select
Pharmacy
Other facility type specify
Please Select
Option 1
Option 2
Option 3
Ordering Provider Name
Please Select
ELIZABETH LOCKLEAR, PHARMD
Ordering Provider Phone
Please Select
910-210-2030
NPI
Please Select
1942464540
Ordering Provider Address
Please Select
7910 US HWY 117, SUITE 110
ROCKY POINT, NC 28457
Ordering Provider City
Please Select
ROCKY POINT
Ordering Provider Zip Code
Please Select
28457
Ordering Provider County
Please Select
PENDER
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
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
82
83
84
85
86
87
88
89
90
91
92
93
94
95
96
97
98
99
100
101
102
103
104
105
106
107
108
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
BRUSNWICK
COLUMBUS
DUPLIN
NEW HANOVER
ONSLOW
PENDER
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.
Format: (000) 000-0000.
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
CareStart COVID-19 ANTIGEN
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: