COVID-19 Rapid Antigen Test

2521 13th Street, Suite A

St Cloud, FL 34769

407-892-7166

www.unlimitedrx.com
COVID-19 Nasal Swab Rapid Antigen Test

NOTE: This test is $45.00 out of pocket we are unable to bill insurance at this time. We will produce results on site and provide report for documentation. There are no refunds, however if the test is inconclusive we will retest at no charge.
SDOC Employees ONLY

Please bring a prescription form your doctor or provider for billing purposes. Also, bring your insurance card and identification to the appointment. Thanks!
Name *

First Name Last Name
Date of Birth *

Month Day Year
Gender *

Male Female
Race *
Ethnicity *
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Cell Phone Number (For call/text when results ready) *
Please enter a valid phone number.
Appointment *
Email *
example@example.com
By signing below, I authorize my test results to be texted to the phone # above. If results are positive, I acknowledge that I will quarrantine in accordance with CDC guidelines. I understand that antigen tests are not 100% accurate and after exposure it may take up to 72 hours to yield a positive result. I attest that I am the patient, caregiver or responsible party for anyone under 18 years old.
Signature *

Clear
Date *

Month Day Year

PHARMACY USE ONLY

	LOT #	EXP DATE	RESULT (POS/NEG)	RPH NAME	RPH SIGNATURE
QUIDEL QUICKVUE COVID-19 ANTIGEN
INDICIAD COVID-19 ANTIGEN