Felicity Pharmacy Rapid COVID-19 Test Form

1
Schedule your Appointment* This field is required.Please select an available 15-min time slot
2
Result
NOT DETECTED FOR SARS-CoV-2/COVID-19
DETECTED/POSITIVE FOR SARS-CoV-2/COVID-19
3
Rapid Test Selection ($40 for Rapid Antigen Test and $100 for RT-PCR Test)* This field is required.There is a fee associated with these tests
SARS-CoV-2 Rapid Antigen Test ($40.00)
SARS-CoV-2 RT-PCR Test/Mesa Accula ($100.00)
4
Date of Test
Month
Day
Year
5
Patient Name* This field is required.
First and Last Name
6
Date of Birth* This field is required.MM/DD/YYYY
MM/DD/YYYY
7
Gender* This field is required.Male, Female, Transexual, Unknown
Male
Female
Transexual
Unknown
8
Pregnant or Post-Partum* This field is required.Please Select One
Yes
No
Unknown
9
Cell Phone Number* This field is required.
10
Address* This field is required.
Street Address
Apt #
City
Please Select
Please Select
NY
NJ
CT
PA
State
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
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
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
11
Email *
example@example.com
12
Race* This field is required.Required by the CDC
Black/African American
White
Asian
American Indian or Alaska Native
Native Hawaiian Or Pacific Islander
Unknown
Other
Please Pick One
13
Ethnicity* This field is required.Required by the CDC
Hispanic/Latino
Not Hispanic/Latino
Unknown
Please Pick One
14
ICD-10 Code* This field is required.Symptoms/ Reason for getting test
Z03.818 Possible exposure to COVID 19, ruled out
Z03.818 Possible exposure to COVID 19, ruled out
Z11.59 Asymptomatic, no known exposure, results unknown or negative
R05 Cough
R06.02 Shortness of breath
R50.9 Fever unspecified
No Diagnosis, Testing for Travel Purposes
15
Signature* This field is required.By signing below you are giving the consent to be tested for COVID-19 via a mid-nasal swab. The testing is to comply with New York State Regulations. You will be provided with a copy of the test results and which COVID-19 test was used in the testing. All standard HIPPA regulations will be followed. A copy of the Felicity Pharmacy’s HIPPA Policy Practices is available upon request. Test results as per New York State mandate will be reported to the appropriate administration of Felicity Pharmacy, the New York State ECLRS System and The New York Health Department
ClearPatient Or Guardian Signature
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