COVID-19 Information and Testing

Which test would you like to schedule?

Antigen tests (COVID TEST - $90)
Antibody test ($50)

Choose an available time on our shedule and fill out the form below.*

Name*

First Last

Phone*

Email*

COVID-19 Rapid Test Consent Form

Once you have arrived for your appointment, please pull to the rear of our building under drive thru sign and call us at 704-735-9072 to let us know you are here. A staff member will come outside and perform the test in your car. We ask that you remain in your car at all times. During the test, pull your mask down just below your nose, but keep your mouth covered. You will get your results in approximately 15 minutes. Note: this is a HIPAA secure platform - your information will remain confidential.

Consent*

I understand that the $90.00 cost of the test is non-refundable and that I will be billed upon appointment confirmation. *

Date of Birth (00/00/0000)*

Address*

Street Address Address Line 2 City State ZIP Code

Primary Care Provider and Location*

Gender*

Race*

Ethnicity*

Make/Model & color of vehicle you will be in during testing:*

Do you have symptoms that you believe to be associated to an active COVID-19 infection?*

These can include dry cough, fever or chills, shortness of breath or difficulty breathing, new loss of taste or smell. For an extensive list see https://www.cdc.gov/coronavirus/2019-ncov/symptoms-testing/symptoms.html. This page includes a self-checker to help you make decisions on when to seek testing.

Yes
No

Have you recently been exposed to someone known to be infected with COVID-19?*

Yes
No

If yes, has it been greater than 48 hours since the exposure?

Yes
No

Are you interested in being tested because you are traveling?

Yes
No

How many people need to be tested during this appointment?

2nd Person Name

First Last

2nd Person Birthdate

3rd Person Name

First Last

3rd Person Birthdate

4th Person Name

First Last

4th Person Birthdate

Credit Card Number

Optional: If you'd like to pay with Credit Card ahead of time

Expiration Date

CVV code

By checking this box, I consent to being tested for COVID-19 by Keever pharmacy. I give consent to Keever Pharmacy to send my testing results to the North Carolina Department of Health and Human Services and Lincoln County Department of Health. **

COVID-19 Questionnaire

COVID-19 Rapid Test Consent Form