NOTE: THIS FORM IS NOT FOR THE VACCINE.
THIS FORM IS FOR THE RAPID NASAL SWAB TEST.
COVID-19 Test Appointment & Consent Form
Rapid COVID-19 Testing; Same Day Results; Cost: $65 with an appointment, $75 without an appointment
PLEASE CALL 605-223-9200 To Reserve An Appointment Time. Fill this form out online prior to coming for your appointment. Please note our new location is at 213 E Hustan Ave in Fort Pierre (between Perkins and Dakota Prairie Bank). When you arrive for your appointment kindly park in the parking spots facing Dakota Prairie Bank and call to let us know you have arrived.
Thank you for Trusting Shane's Pharmacy!
Patient Name
*
First name
Middle Initial (Optional)
Last name
Date of birth (MM/DD/YYYY)
*
 /
Month
 /
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Address
*
Street Address (and unit/apt # if applicable)
Street Address Line 2
City
State / Province
Zip code
State
*
Please Select
AL
AK
AZ
AR
CA
CO
CT
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
You may choose a different option if your State is different
Phone Number
*
Format: (000) 000-0000.
Gender
*
Please Select
Male
Female
Are you Pregnant
*
Please Select
Yes
No
N/A
List any allergies to medications
What is your occupation?
*
Do you reside in a group home?
*
Please Select
Yes
No
If Yes, Please list Name of Facility
Primary Care Providers Name
Race (select all that apply)
*
Unknown
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or other Pacific Islander
White
Other race (specify)
Ethnicity
*
Hispanic or Latino
Not Hispanic or Latino
Unknown
Have you had a POSTIVE COVID-19 test in the last 3 months ?
*
Yes
No
Have you had direct exposure to COVID-19?
*
Yes
No
Unsure
Approximately how many days ago were you exposed to COVID-19?
List your symptoms
*
No Symptoms
Cough
Shortness of breath or difficulty breathing
Fatigue
Muscle or body aches
Headache
New loss of taste or smell
Congestion or runny nose
Nausea or vomiting
Diarrhea
Fever or Chills
Sore throat/Hoarseness
Approximately how many days have you been experiencing symptoms?
Have you been hospitalized or been admitted to ICU recently?
*
Please Select
Yes
No
List any travel history in the last 14 days
Signature **By signing below, I give consent to Shane's Pharmacy to send my test results to the South Dakota Health Department and if request to my Primary Care Provider**
*
Today's Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
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