RAPID COVID TEST PATIENT INFO

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

APPOINTMENT ONLY
Please call (912)-490-7777 to schedule your testing time.
CASH PRICE $55.00.
CARD PRICE $57.00.
Please have payment ready when you get here.

Email *

DATE OF APPOINTMENT: *

YYYY

FIRST NAME: *

LAST NAME: *

Street Address: *

City: *

State: *

Zip Code : *

COUNTY... (NOT THE USA) *

Phone #: *

Secondary #:

DOB: *

YYYY

Have you tested positive for covid 19 in the past? If yes when. *

Have you received the covid 19 vaccine. If so which one and when? *

Reason for testing: *

Exposure

Symptoms

Retest

Required

If this is a retest, when were you tested positive?

Symptoms: *

Cough

Shortness of breath

Nausea / vomiting

Diarrhea

Loss of tase / smell

Fever / chills

Sore Throat

Congestion / runny nose

Headache

None

Required

If tested positive, would you like to be treated by our providers? *

Yes

Allergies to medication: *

What pharmacy (and location) do you use? *

I understand Faith Family Practice is offering RAPID COVID TESTING as a SELF PAY service only. Due to the high volume of tests Faith Family Practice will NOT be able to file your insurance, under any circumstances. If your test is Positive you will need to see your Primary Care Physician (PCP) for treatment. If you do not have a PCP our Providers will be glad to treat you. Call 912-490-7777 for an appointment with our providers. I understand and agree to the above statement; I also consent to pay for this service as a self-pay service only. *

I AGREE

Required

Submit

Clear form

Never submit passwords through Google Forms.

This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy

Forms