Covid -19 Rapid Test
  • Diabetes
  • Obesity
  • Asthma
  • Immune System deficiencies/HIV
  • Serious heart conditions
  • Kidney disease needing dialysis
  • Liver disease
  • Cancer or corticosteroid use
  • Bone marrow/ organ transplant
  • Hemoglobin disorders
  • Other _______________________
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Method of Payment
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Below line will be filled out by administrator:
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Date administered: _________
Time Given: __________
Time Read: __________
Lot #: __________
Expiration: __________
Test Type: BD Veritor / Carestart
Positive - Self isolate until (date) ________________ (10 days after onset of symptoms)
Negative
Administered by:______________________ Signature: ______________________________ Title ____________