COVID-19 PCR TEST FORM

Please fill out the following form to help us understand your physical condition. Submissions are REQUIRED before you drive up for Covid 19 PCR Test.

Covid testing is NOT FREE anymore.

First Name

Last Name

Date of Birth

Gender

Male

Female

Street Address, City, Zip Code

Phone

Email Address

Do you have any symptoms?

Yes

I declare that the info I’ve provided is accurate & complete

By checking this box and typing my name below, i also consent to COVID-19 testing for me/my dependent and acknowledge that i agree to the statements contained in the Informed Consent for COVID-19 Testing Document provided before performing the test and i further acknowlege that i have read and recieved a copy of Brass Mill Pharmacy's Notice of Privacy Practices (NPP)

Test Performed: SARS-CoV-2 (COVID-10) RT-PCR (Nasal Swab). ** Z11.52

Photo of your ID card

Photo of Insurance Card

Your Signature

Please remain in your Vehicle with windows rolled up as we prepare for your test.
Once you arrive - Please call us at 203-721-8022 and let us know.

BRASS MILL PHARMACY IN WATERBURY CT

BRASS MILL PHARMACY IN WATERBURY CT

Point of Care

PCR TESTING IS NOT FREE
Results will not be provided if you don't provide Insurance Information or Cash payment

$35.00

COVID-19 PCR TEST FORM

Please remain in your Vehicle with windows rolled up as we prepare for your test.
Once you arrive - Please call us at 203-721-8022 and let us know.

COVID-19 PCR TEST FORM

Please remain in your Vehicle with windows rolled up as we prepare for your test. Once you arrive - Please call us at 203-721-8022 and let us know.

Please remain in your Vehicle with windows rolled up as we prepare for your test.
Once you arrive - Please call us at 203-721-8022 and let us know.