Village Apothecary
COVID-19 Testing Screening and Consent Form
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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
First Name *
Enter PATIENT first name. Do not enter middle name or middle initial
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
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.
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.
Street Address *
City *
State / *
Use only 2 letter abbreviation (i.e. NY)
Zip Code *
Please enter 5 digit zip code
County *
Phone *
Please use mobile phone number (in the event of a positive). Valid Format: 555-555-5555
Pregnant or Post Partum *
Primary Care Provider *
Full Name, Phone Number
Are You A Student or An Employee Of A School District? *
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