Point of Care Testing Form

2521 13th Street, Suite A

St Cloud, FL 34769

407-892-7166

www.unlimitedrx.com
503 E 1st Street

Sanford, FL 32771

407-323-6413

www.unlimitedrx.com
Point of Care Testing Form and Screening

NOTE: We are unable to bill for insurance for these tests 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 from your doctor or provider for billing purposes. Also, bring your insurance card and identification to the appointment.
Select Test Request

SARS-COV2Influenza A+B / SARS-COV2 (Coming soon!)Strep A (Coming soon!)
Patient Name*

First Name Last Name
Date of Birth*

MonthDay Year
Gender*

MaleFemale
Race*
Ethnicity*
Address*

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Caregiver Name (if different from patient)

First Name Last Name
Cell Phone Number (For call/text when results ready)*
Please enter a valid phone number.
Email (for test results via email)*
example@example.com
Appointment*
Select Location*

Saint CloudSanford (Tru-Valu Drugs)Osceola Schools Health Center (Employees and dependents ONLY) - COMING SOON!

Health Screening Questions