Surveypoint

Q1

Agree to Terms & Conditions. By continuing, you agree: You are 18 years old or older or 2) the parent or legal guardian of a minor patient 3 years old or older or 3) the legal guardian of the patient in Nebraska - Parent or legal guardian consent is required for testing individuals under the age of 19 in Puerto Rico - Parent or legal guardian consent is required for testing individuals under the age of 21 You're not experiencing severe symptoms such as severe shortness of breath, continuous pain or pressure in the chest, or persistent fever greater than 102ºF. If you're experiencing severe symptoms, please seek medical attention immediately. You acknowledge that your or the minor patient’s information will be used as described in the iPharma Pharmacy Notice of Privacy Practices Opens in a new tab. You acknowledge that your information will be used as described in iPharma Pharmacy Notice of Privacy Practices You agree to receive email communications that contain information about your or the minor patient’s eligibility for COVID-19 testing and COVID-19 testing appointments. By selecting "I agree" below, you also have read and accept iPharma Pharmacy Terms of Use Opens in a new tab*

I accept

I decline

Q2

First Name

Enter Patient Information*

Q3

Last Name

Enter Patient Information*

Q4

Patient gender*

Please Select

Male

Female

Other

Q5

Patient date of birth*

Q6

Patient race*

Please Select

American Indian or Alaska Native

Asian

Black or African American

Native Hawaiian or Other Pacific Islander

White

Decline to Answer

Q7

Patient Ethnicity*

Please Select

Hispanic or Latino

Non Hispanic or Latino

Decline to Answer

Q8

Street Address

Address*

Q9

Street Address Line 2

Address*

Q10

City

Address*

Q11

State / Province

Address*

Q12

Postal / Zip Code

Address*

Q13

Email*

Q14

Phone Number*

Q15

COVID-19 Test Questionnaire Please answer all questions to the best of your ability to determine your eligibility for COVID-19 testing.1. Do you currently have any of the following symptoms? (Select all that apply)*

Fever less than 102°F or feeling feverish

Chills

Repeated shaking with chills

New or worsening cough

Sore throat

Shortness of breath or difficulty breathing (not severe)

Muscle pain

Headache

New loss of taste or smell

Nausea, vomiting or diarrhea

None of the above

Q16

In the last 14 days, have you had contact (been within 6 feet of an infected person for a cumulative total of 15 minutes or more over a 24-hour period, starting from 2 days before illness onset until the time the infected person is isolated) with someone who's been diagnosed with (or is presumed to have) COVID-19?*

Yes

No

Q17

In the last 2 weeks, have you been in contact (within 6 ft. of the person for a prolonged period of time or been coughed on) with someone who is sick but has not been diagnosed with COVID-19?*

Yes

No

Q18

In the last 2 weeks, have you had any of the following exposures? (Select all that apply)*

International travel

Live in or have visited an area where there has been community spread of COVID-19

None of these

Q19

Do any of the following describe your work setting? (Select all that apply)*

Healthcare Facility: I work in a clinic, hospital, nursing home, or senior care facility or other healthcare facility

First Responder: I am a first responder, such as an ambulance worker, law enforcement officer, or firefighter

None of the above

Q20

Do you have any of the following conditions? (Select all that apply)*

Chronic lung disease or moderate to severe asthma

Serious heart condition (including high blood pressure, previous heart attacks, heart failure, etc.)

I have a neurologic condition that affects my ability to cough (e.g., had a stroke)

Condition that can cause a person to be immunocompromised (including cancer treatment, smoking, bone marrow or organ transplant, immune deficiencies, HIV positive, prolonged use of corticosteroids and other immune weakening medications)

I smoke

I have been told by my doctor that I am very overweight or obese (body mass index [BMI] of 40 or higher)

Diabetes

Chronic kidney disease or undergoing dialysis

Liver disease

None of the above

Q21

Are you currently pregnant?*

Yes

No

Does not apply to me

Q22

Have you received the COVID-19 vaccine?*

Yes

No

Prefer not to specify

Q23

If yes, which vaccine did you receive?

Please Select

Johnson & Johnson

Pfizer

Moderna

Other

Q24

Date of vaccination, first dose

Q25

Date of vaccination, second dose

Q26

Available Tests, please select one

Rapid Diagnostic Test (ID Now)

Diagnostic Lab Test (PCR)

Rapid Antigen Test (Binax Now)

Q27

Insurance

Yes, I do have insurance

No, I am uninsured patient

Q28

Driver's License State

Q29

Driver's License Number

Q30

Covid 19 Testing Appointment Request -Form Fill

First Name

Last Name

Patient gender*

Patient date of birth*

Patient race*

Patient Ethnicity*

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Email*

Phone Number*

COVID-19 Test Questionnaire Please answer all questions to the best of your ability to determine your eligibility for COVID-19 testing.1. Do you currently have any of the following symptoms? (Select all that apply)*

In the last 2 weeks, have you been in contact (within 6 ft. of the person for a prolonged period of time or been coughed on) with someone who is sick but has not been diagnosed with COVID-19?*

In the last 2 weeks, have you had any of the following exposures? (Select all that apply)*

Do any of the following describe your work setting? (Select all that apply)*

Do you have any of the following conditions? (Select all that apply)*

Are you currently pregnant?*

Have you received the COVID-19 vaccine?*

If yes, which vaccine did you receive?

Date of vaccination, first dose

Date of vaccination, second dose

Available Tests, please select one

Insurance

Driver's License State

Driver's License Number

Signature