I understand that I am scheduling to receive testing for COVID-19 for myself or a minor on whose behalf I am authorized to provide consent. I have been informed that testing is voluntary, that I have the right to decline any tests and that positive test results will be reported to the state health department where required by law. I consent to testing for COVID-19 and agree to these terms. I acknowledge that I have received a copy of the Notice of Privacy Practices (PDF).

I HEREBY GIVE MY CONSENT To the pharmacist and pharmacy staff members from Pineville Pharmacy to perform a Covid-19 Rapid Antigen Test and/or PCR test at my own risk and authorize the Pineville Pharmacy and it’s staff member to maintain a copy of this signed form. On behalf of myself, my heirs, and personal representatives, I indemnify the organizing body and all persons connected with Pineville Pharmacy from all claims that may result from my voluntary participation in the tests. I also give my consent to submit my or my representatives results to the North Carolina Department of Health or any other healthcare agency, as required by law. By signing below or submitting this form, I signify that I agree to allow those pharmacists affiliated with the pharmacy named above to administer the Covid-19 test for a listed price above ($110 for rapid antigen test and $149 for PCR test).

I further agree: The cost for the test is non-refundable and I am fully responsible for the payment before the test is performed. I also agree that I will not seek any reimbursement from Pineville Pharmacy, employees, and their officers. I understand that the rapid antigen tests look for viral proteins, which are highly specific, meaning that if you test positive, you are very likely infected. However, there is a higher chance of false negatives with antigen tests, which means that a negative result cannot definitively rule out an active infection. If you have a negative result on an antigen test but have a recent exposure to COVID, or are displaying many of the symptoms, you may wish to take a PCR test to confirm your result. A PCR test looks for the presence of the virus's genetic material. PCR tests are highly accurate but can take days to a week to get the results. The antigen test that you are receiving today is most accurate if you are symptomatic and within the first five days of symptoms. If you are testing to meet a travel requirement, it is your responsibility to determine if you are required to take a PCR test or an antigen test.