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COVID-19 Antigen or PCR Testing Consent Form
DANIEL DRUG
3409 W 7th St, Fort Worth, TX 76107
Phone : (817) 332-6386
CLIA ID NUMBER : 45D2246663
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Email
*
Your email
First Name
*
Your answer
Middle Name
Your answer
Last Name
*
Your answer
Date of birth
*
MM
/
DD
/
YYYY
Phone number
*
Your answer
Select the COVID test
*
Rapid Antigen Test (30 mins) - $79
PCR Test (1-2 hours) - $169
Gender
*
Male
Female
Other
Race
*
American Indian or Alaskan Native
Asian
Black or African American
Native Hawaiian or Pacific Islander
White
Other
Unknown
Ethnicity
*
Hispanic
Non-Hispanic
Unknown
Reason for Testing
*
Contact with COVID-19, suspected exposure
Having symptoms such as cough, sore throat, loss of smell/taste, etc.
Asymptomatic, no known exposure, for screening purposes only
Possible exposure to COVID-19
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