COVID Test Prescreening - Good Pharmacy

After completing the prescreening questionnaire below, you will be redirected to the online payment page. If you wish to pay at your appointment, please ignore the online payment page.

First Name *
Last Name *
Date of Birth *
Phone *
Email *PLEASE DOUBLE CHECK YOU HAVE INPUT YOUR EMAIL CORRECTLY. (This is where your confirmation and receipt will be sent)
Is the patient a minor (less than 18 years old)? *
YesNo
If the patient is a minor, please enter the Legal Guardian's First and Last Name
Street Address *
City *
State *
Zip *
Sex *
Race *
WhiteBlack/African AmericanAmerican Indian/Alaska NativeNative Hawaiian/Pacific IslanderAsianOtherUnknown
Ethnic Origin *
HispanicNon-Hispanic
Are you currently experiencing any COVID or COVID-like symptoms?
CoughFever/ ChillsShortness of BreathSore ThroatRunny NoseSneezingOtherUnknownAsymptomatic (No Known Symptoms)
Date of Symptom Onset: Rapid Antigen Tests are best utilized for detection around 5 days after exposure/infection. PCR Molecular Tests can detect infection within 24 hours of exposure/infection.
KnownUnknownN/A
If Known, please enter the Date of Symptom Onset (MM/DD/YYYY)
Please check any of the boxes below that you are associated with:
Child Care (child/household contact/worker in child care)School (student or worker)College/University (student or worker)Food Service (food worker)Health Care (healthcare worker)Correctional Facility (inmate or worker)Long Term Care (resident or worker)Military (active military/defendant/recent retiree)Travel (outside continental US in last 30 days)
How did you hear about us? Or who referred you? *
Type of Vehicle you will be in at curbside? PLEASE MAKE SURE TO INCLUDE MAKE, MODEL AND COLOUR
I certify that I am: *
(a) The Patient and at least 18 years of age or
(b) The Parent or legal guardian of the patient.I have read and agree to the terms above
Further, I hereby given my consent: *
To the healthcare provider of Good Pharmacy, as applicable (each an "applicable Provider"), to administer the COVID-19 test(s) I have requested above. I understand that it is not possible to predict all possible side effects or complications associated with receiving a COVID-19 test(s). I understand the risks and benefits associated with the above COVID-19 test(s) and have received, read, and/or had explained to me the information pertaining to the COVID test(s) I have selected and all of my questions have been answered by a Good Pharmacy staff member to my satisfaction. On behalf of myself, my heirs and personal representatives, I hereby release and hold harmless the applicable Provider, its staff, agents, successors, divisions, affiliates, subsidiaries, officers, directors, contractors and employees from any and all liabilities or claims whether known or unknown arising out of, in connection with, or in any way related to the administration of the COVID test(s) listed above.I have read and agree to the terms above
I voluntarily: *
Authorize and direct my healthcare provider, Good Pharmacy to use or disclose my health information during the term of this authorization to any Physician, State or Federal Board or Agency, or Insurance Company, as required, for the purpose of treatment, payment, or other healthcare operation.I have read and agree to the terms above
I Further Agree: *
To be fully financially responsible for the full cost of this COVID test(s) as listed above. I understand that any payment for which I am financially responsible for is due prior to the time of service, for which the Good Pharmacy healthcare Provider will provide receipt of such invoice. There are no refunds once acknowledgment and payment information has been made. I agree to come in for testing and will not be issued any refunds for any reason whatsoever once I have agreed to these terms.I have read and agree to the terms above
Refund Policy *
There are no refunds for COVID testing once you confirm payment. You can reschedule to another date and time or we can offer you a free test voucher, should you miss your scheduled testing appointment.I have read and agree to the terms above

Verification

Please enter any two digits *Example: 12
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