COVID Intake Form

1
Name* This field is required.
First Name
Last Name
2
Phone Number* This field is required.
Area Code
Phone Number
3
Date of Birth * This field is required.
Date
Month
Day
Year
4
Email AddressPlease provide your email address. We will email you a copy of this form. You WILL NOT receive a copy of this form if you do not provide an email address. Click Next if you do not have an email address.
example@example.com
5
Address* This field is required.Please provide your home address.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
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Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curacao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
6
Gender * This field is required.Please type in your Gender
7
Race * This field is required.Required by CDC
American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latino
Native Hawaiian or Other Pacific Islander
White
Other
8
ICD-10 Code* This field is required.Please select one that best describes your exposure
Contact with and have suspected exposure to other viral communicable disease (Z20.828)
Asymptomatic, with no known exposure, results unknown or negative. (Z11.59)
9
PLEASE READ CAREFULLY! Please arrive 5 minutes early for your scheduled test time. We are located at 393 Piaget Ave Clifton NJ 07011. Testing will be located in the rear parking lot of the building. Call 844-563-3722 upon your arrival. Please stay in your vehicle until further directions are given. DO NOT ENTER THE PHARMACY. There will be a PDF File attached to your email. The password to open the file is Testing123! Also, we are working diligently to make sure you are in and out according to your scheduled time, however, there might be some unforeseen delays that occur. We ask you to be patient with us. We are working as fast and carefully as possible. So, please allow some time in your day if a delay were to occur. If you have any questions about the above statement you can reach out to us directly at the number listed above. Thank you. Please click YES to acknowledge the above statement.* This field is required.
YESNO
10

Testing Hours

(Subject to change)

Monday - Friday - 10am-5pm

Saturday - 10 am -2:30pm

Sunday - Closed
11
Please save this for your records

Ordering Facility

Middle Village Pharmacy

393 Piaget Ave Clifton, NJ 07011

CLIA Number: 31D2195423

Phone: 973-478-0600

Pharmacist in Charge

Name: Bhaveek Mistry

License Number:28RI03665500

NPI: 1194191361

Ordering Physician

New Jersey Department of Health Issuing Official

Name: Andrew L Falzon, MD

License Number: 25MA07270200

NPI: 1689186579
12
Appointment * This field is required.
13
COVID-19 Tests* This field is required.Please read each description carefully and choose the tests is best for your end user.
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ORDER SUMMARY
Total costUSD
Rapid PCR --------(by Abbot ID NOW system M-PCR COVID-19 Test)M-PCR Test via Abbott ID NOW system
$178.00+Edit
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Rapid ANTIGEN (FLU & COVID-19) BD Antigen test. Tests for both Flu and COVID-19
$108.00+Edit
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Total cost $0.00
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