Covid Testing - Rivertowns Pediatrics of Staten Island

Rivertowns Pediatrics of Staten Island is now doing PCR and Rapid Covid Tests!

No need to be a member. Call or email to schedule your appointment!

$150 Payable by cash or Check

RM_Stats

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General Information:

First Name

Last Name

Date of Birth

Address

Phone Number

Email

Gender

Male

Female

Pregnant or Postpartum?

Employer/ School information:

Employer Name or School District Name:

Employer Address:

Employee Job Title:

Employer Phone Number:

Additional Covid Information:

Is this your first test?

Are you a healthcare worker?

Do you have symptoms?

Date Symptoms Started:

Insurance Card:

Insurance Card

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Covid Test Consent

This consent provides Rivertowns Pediatrics of Staten Island with your permission to perform a rapid COVID-19 screening procedure, as you have requested. By signing below, you are indicating that you voluntarily consent to this procedure for the detection of COVID-19. The test being administered involves a nasal swab that will be tested to indicate the potential presence of COVID-19. Rivertowns Pediatrics of Staten Island uses the BD Veritor System for Rapid Detection of SARS-COV-2 Antigen. This test has been approved by the FDA under Emergency Use Authorization , however, this test alone may not be sufficient to detect or rule out the possibility that you have been exposed to or are infected with COVID-19. You should carefully monitor your own symptoms and, notwithstanding the results of any testing, you must stay home and consult with your physician if you experience symptoms of COVID-19. You authorize Rivertowns Pediatrics of Staten Island to confirm a negative test result by sending your sample to a laboratory for further testing. You will be responsible for any co-pays, deductibles, or other costs the laboratory may charge. The New York State Department of Health requires Rivertowns Pediatrics of Staten Island to report to it the results of your test, whether positive or negative. By signing below, you consent to the disclosure of such information. By signing below, you agree to release and waive any claim arising from your election to receive this voluntary screening that may arise against Rivertowns Pediatrics of Staten Island and its designated medical providers and staff members. Additionally, you agree to release and waive any claim that might arise against Rivertowns Pediatrics of Staten Island and its designated medical providers and staff members for any risks, side effects, or complications resulting from the testing.

By submitting this form you confirm that you have read and understood our Terms and Conditions.