Cashiers Valley Pharmacy COVID-19 Testing Form

Cashiers Valley Pharmacy

52 Cashiers Shopping Center, Cashiers, NC 28717
Cashiers Valley Pharmacy COVID-19 Testing Intake Form
Name

First Name Last Name
Date of Birth

Month Day Year
Date
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
County of Residence
Email
example@example.com
Phone Number
Please enter a valid phone number.
Race

American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander White Prefer not to answer
Ethnicity

Hispanic or Latino Not Hispanic or Latino Prefer not to answer
Today's Date

Month Day Year
Date
Appointment
Do you have any of the following symptoms? (Check all that apply)

Fever or chills Cough Shortness of Breath or difficulty breathing Fatigue Muscle or body aches Headache New loss of taste or smell Sore throat Congestion or runny nose Nausea or vomiting Diarrhea
Have you had known or suspected exposure?

Yes No
IMPORTANT THINGS TO KNOW:

1. The pharmacy is unable to bill most medical insurance payers. The price of the test is $99 plus tax and you will be charged at the time of testing. We will provide you with a Universal Claim Form, which may be submitted to your insurance for reimbursement.

2. When you arrive, please REMAIN IN YOUR VEHICLE. Call us at 828-743-3114 to let us know you are parked outside the pharmacy and we will come to your car to conduct your test. We ask that you wait in your car for your test results, which will be provided within 15 minutes from the time the test is administered.

By signing below, you acknowledge that you have read and will adhere to these policies.
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Cashiers Valley Pharmacy

Cashiers Valley Pharmacy COVID-19 Testing Intake Form