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Available Forms

**Rapid COVID-19 intake

Rapid COVID Test

This test is 100.00 out of pocket. HSA funds may be used to cover the cost or the patient can submit a form for reimbursement to their medical insurance.

street, lot #, apt #
Test results & work/school excuse will be sent via text message unless requested otherwise
*If paying with card, have card ready to present for payment processing.


Example: recent travel (please include location), contact with another lab-confirmed COVID-19 case, clearance for surgery, return to work, etc.)

Pre-existing medical conditions

(neurodevelopmental/intellectual disabilty)

Consent and Date

I give Surgoinsville Pharmacy consent to perform the test and evaluation most appropriate for myself or child. I consent for the lab to bill my insurance as appropriate.


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