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Village Apothecary
COVID-19 Testing Screening and Consent Form
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* Required
Email
*
Your email
EMAIL CONFIRMATION
Please review the email you typed above to ensure accuracy. We are not responsible for test results that are sent to incorrect email addresses.
We will NOT send test results to third party organizations. Use work or personal email only.
Patient Demographic Information
Last Name
*
Enter PATIENT last name and suffix, if applicable
Your answer
First Name
*
Enter PATIENT first name. Do not enter middle name or middle initial
Your answer
DOB
*
Enter PATIENT date of birth
MM
/
DD
/
YYYY
Race
*
Which of the following best describes your race? Note: These descriptors are set by NY, not by Village Apothecary. Answering is mandatory. Select other if you do not wish to share this information
Asian or Pacific Islander
Black or African American
Native American or Alaskan Native
Multiracial
White
Other
Ethnicity
*
Which of the following best describes your ethnic group? Note: These descriptors are set by NY, not by Village Apothecary. Answering is mandatory. Select other if you do not wish to share this information.
Hispanic or Latino
Not Hispanic or Latino
Unknown / Other / Prefer not to answer
Gender
*
Note: These descriptors are set by NY, not by Village Apothecary. Answering is mandatory. Select other if you do not wish to share this information.
Male
Female
Other
Transexual
Unknown / Prefer Not to Answer
Hermaphrodite / Undetermined
Street Address
*
Your answer
City
*
Your answer
State /
*
Use only 2 letter abbreviation (i.e. NY)
Your answer
Zip Code
*
Please enter 5 digit zip code
Your answer
County
*
Your answer
Phone
*
Please use mobile phone number (in the event of a positive). Valid Format: 555-555-5555
Your answer
Pregnant or Post Partum
*
Yes
No
Primary Care Provider
*
Full Name, Phone Number
Your answer
Are You A Student or An Employee Of A School District?
*
Yes, I am a student or employee of a school district.
No, I am not a student or employee of a school district.
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