Onteora CSD COVID-19 Testing Registration

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Dr. Neal Smoller, PharmD is a pharmacist and owner of Village Apothecary in Woodstock.

Dr. Neal is partnering with local school districts to provide testing to meet the recent NY mandates in light of COVID-19.

Please read this entirely and fill out the required details below.

If completing this on behalf of a minor, please complete the document with the student's information in each of the fields. The document must be signed by a parent or legal guardian. If the patient is a student but 18 years of age, they can complete the document on their own behalf.

𝗡𝗢𝗧𝗘: 𝗜𝗳 𝘆𝗼𝘂 𝗵𝗮𝘃𝗲 𝗮𝗹𝗿𝗲𝗮𝗱𝘆 𝗿𝗲𝗴𝗶𝘀𝘁𝗲𝗿𝗲𝗱 𝘂𝘀𝗶𝗻𝗴 *𝗧𝗛𝗜𝗦 𝗙𝗢𝗥𝗠* 𝘆𝗼𝘂 𝗱𝗼 𝗻𝗼𝘁 𝗵𝗮𝘃𝗲 𝘁𝗼 𝗱𝗼 𝗶𝘁 𝗮𝗴𝗮𝗶𝗻.

Email *

Section I. Personal Information

Last Name *

Enter patient's last name.

First Name *

Enter patient's first name. Do NOT write middle initials.

DOB *

Enter patient's date of birth.

YYYY

Race *

Which of the following best describes your race? Note: These descriptors are set by NY, not by Village Apothecary. Answering is mandatory. Select other if you do not wish to share this information.

Asian or Pacific Islander

Black or African American

Native American or Alaskan Native

Multiracial

White

Other

Unknown

Ethnicity *

Which of the following best describes your ethnic group? Note: These descriptors are set by NY, not by Village Apothecary. Answering is mandatory. Select other if you do not wish to share this information.

Hispanic or Latino

Not Hispanic or Latino

Unknown / Other / Prefer not to answer

Gender *

Note: These descriptors are set by NY, not by Village Apothecary. Answering is mandatory. Select other if you do not wish to share this information.

Male

Female

Other

Transexual

Unknown

Hermaphrodite/Undetermined

Street Address *

City *

State *

Use only 2 letter abbreviation (i.e. NY)

Zip Code *

Please enter 5 digit zip code

Phone *

Please use mobile phone number (in the event of a positive). Valid Format: 555-555-5555

Section II: School Information

School District Name *

Onteora CSD

School Affiliation *

Please select your affiliation with the school

Faculty

Staff

Student

Family Member of Student

School Name *

Select the school you attend or work for. If you are associated with transportation, building and grounds, or administration, please select the High School, or the building you are best affiliated with.

Onteora High School

Onteora Middle School

Phoenicia Elementary School

Reginald Bennet Elementary School

Woodstock Elementary School

Section III: Consent

Please read the following statements carefully and check each box to acknowledge your consent *

Understood And Acknowledged

I understand and acknowledge that an electronic copy of Village Apothecary's COVID-19 School Testing FAQs is available at drneal.co/testfaq and that I may request a hard copy at any time.

I authorize Village Apothecary to conduct specimen collection and testing for COVID-19 by nasal swab using the Abbott BinaxNOW COVID-19 Antigen test, as ordered by an authorized medical provider/public health official.

I understand that possible discomfort or other complications, such as the potential for a bloody nose, can happen during sample collection.

I understand that I will be verbally informed of my test results by the ordering provider or their designee, as specified in the COVID-19 School Testing FAQs document available at drneal.co/testfaq.

I understand that my results will be disclosed to county and state public health officials as required by NYS laws and regulations.

I understand that my results will be disclosed to the school district of which I am employed, attend, or am affiliated with.

I acknowledge that a positive test result will require that I isolate until criteria for discontinuation of isolation is met as outlined by my local Department of Health.

If I receive a positive test result, I will cooperate with local Department of Health and NYS Health Department officials in contact tracing efforts.

I understand that Village Apothecary is not acting as my medical provider, and that this testing does not replace treatment by a medical provider.

I understand that, as with any medical test, there is a potential for false positive or false negative COVID-19 test results. If I receive a negative test result yet develop symptoms that are consistent with COVID-19, I will seek follow up with my medical provider for a molecular PCR lab test.

I understand that, as with any medical test, there is a potential for indeterminate tests, which may require a retest and additional sample collection.

I understand that the test provided has been given FDA Emergency Use Authorization for testing in asymptomatic individuals for detection of COVID-19 infection.

I understand that if I require private space to perform testing, I will communicate that with on-site testing staff and understand there may be a slightly longer wait to accommodate

I understand that if test results are sent via email, I authorize my test results to be sent via traditional email exchange to the email address I've provided.

I understand that if the option to self-swab is given, I must perform sample collection to manufacturers specifications. If I fail to do so, I understand that I or a Village Apothecary staff member will have to re-collect the sample, and I may lose my ability to perform self-swabbing.

I understand and acknowledge that an electronic copy of Village Apothecary's Notice of Privacy Practices is available at drneal.co/vahipaa and that I may request a hard copy at any time.

I understand that Village Apothecary reserves the right to terminate any patient relationship due to policy noncompliance, verbal abuse or violence, inappropriate or criminal conduct, or any reason management deems sufficient. Written notice shall be given to the school district and alternative testing options will be required if I wish to maintain compliance with the NYS mandate.