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Vaccination Group Clinic Form
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Email
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Your email
Confirm Email Address
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Your answer
Which COVID-19 Test would you like to receive?
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Rapid Antigen 10 Minute Test - $125.00
PCR Throat Swab 24 Hour Test - $179.99
PCR Saliva 72 Hour Test - $179.99
Have you experienced any of the following:
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Fever or Chills
Cough
Shortness of Breath or Difficulty Breathing
Fatigue
Muscle or Body Aches
Headache
Loss of Taste or Smell
Sore Throat
Congestion or Runny Nose
Nausea or Vomiting
Diarrhea
No, None of The Above
Required
Within the past 14 days, have you been in close physical contact (6 feet or closer for at least 15 minutes) with a person whi is known to have laboratory-confirmed COVID-19 or with anyone who has any symptoms consistent with COVID-19?
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Yes
No
Are you isolating or quarantining because you may have been exposed to a person with COVID-19 or are worried that you may be sick with COVID-19?
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Yes
No
Are you currently waiting on the results of a COVID-19 test?
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Yes
No
Date of Birth
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Your answer
First Name
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Your answer
Last Name
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Your answer
Street Address
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Zipcode
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Contact Number
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Your answer
Would you be interested in our Immunity Bundle?
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$99.28 (normally $125.00) - Vitamin D3, Zinc 30, PureDefense w/NAC, Melatonin 3mg & Ascorbic Acid - 1 Month Supply for 2 Adults - We can charge your credit card if interested
Yes
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IMMUNITY BUNDLE
Payment
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Pay by Phone - Please call (512) 382-9381
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Credit Card or HSA Card Number
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Expiration Date and 3-Digit Code
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Please Type Your Name Below to Sign
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COVID-19 PCR Screening Consultation Form will be submitted to Solutions Pharmacy
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