BRASS MILL PHARMACY IN WATERBURY CT

BRASS MILL PHARMACY IN WATERBURY CT

(203) 721-8022

WE'LL BE HAPPY TO ASSIST YOU!

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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 Rapid Test.

First Name

Last Name

Date of Birth

Gender

Male

Female

Race/Ethnicity

Address

Phone

Email Address

Are you a member of the following groups: First responders, dispatchers, public works, teachers/school staff, or National Guard

No

Yes

Do you have any symptoms?

No

Yes

If you answered yes to any question, please elaborate

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)

The AccessBio, Inc CareStart COVID-19 Antigen test is a lateral flow immunochromatographic assay intended for the qualitative detection of the nucleocapsid protein antigen from SARS-CoV-2 in nasopharyngeal swab specimens directly collected, or collected in BD universal trasport media from individuals suspected of COVID-19 by their healthcare provider within five days of symptom onset. Brass Mill Pharmacy | 1405 East Main st | Waterbury | CT | 06705. (203) 721-8022. CLIA Waiver ID # 07D2207579

Your Signature

Upload Photo ID/ Drivers License

Upload File

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$100.00

Thanks for submitting!

Please remain in your Vehicle as we prepare for your test.

© 2016 by Brass Mill Pharmacy, LLC | 1405 East Main St | Waterbury | CT 06705 | (203) 721-8022

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