COVID-19 Rapid Antigen Test

2521 13th Street, Suite A

St Cloud, FL 34769

407-892-7166

www.unlimitedrx.com

Laboratory/CLIA ID: 10D2133852

NPI: 1447347638
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.
Name *

First Name Last Name
Date of Birth *

Month Day Year
Date
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.
Email
example@example.com
Appointment *
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.
Signature *

Clear
Date *

Month Day Year

PHARMACY USE ONLY	LOT #	EXP DATE	RESULTS (POS/NEG)	RPH Name	RPh Signature
Quidel Quickvue COVID-19 Antigen	716741	03/18/2022
BinaxNOW COVID-19 Antigen	148122	12/03/2021
Sample Id: _________________ Collection Date/Time:_________________

COVID-19 Nasal Swab Rapid Antigen Test