• Vaccine Consent Form

  • Flu Testing click here

  • Vaccine Consent Form click here

  • Flu Testing Consent Form

    Sona Pharmacy at 805 Fairview Rd, Asheville, NC

  • Carehub

    Sona Pharmacy at 805 Fairview Rd, Asheville, NC

  •  Testing cost $50.

    Payment is due at check-in at the pharmacy.

  •  

    Note: schedule appt 30 in advance

  • *COVID NOTICE*

    We have Moderna's mNexspike available for anyone 65+ years of age OR 12-64 years of age with one underlying condition.

  • Location of Service*
  • Select Carehub Service Type
  • Select Carehub Test
  • Sona Asheville Appointment (805 Fairview Rd)*
  • Sona Asheville Point of Care Testing Appointment (805 Fairview Rd)*
  • Sona Asheville Saturday Appointment
  • Sona Arden Appointment (106 Long Shoals)
  • Sona Arden Saturday Appointment
  • How would you like to fill in your information? (lookup available for patients with active prescriptions in the past two years)

  • Current Profile Information

    Name: {legalFirst} {legalLast} Date Of Birth: {dateOf}
    Address: {address} Physician: {physicianName}
    {city114} {statecode} {zip115} Insurance: {thirdParty}
    Primary phone: {primaryPhone9} MemberID: {memberid} 
    Email: {email} Bin: {rxbin}

  • Patient Information

  • Date of Birth*
     / /
  • Weight and Height

  • *Notice - A prescription from the child's provider is REQUIRED for persons under the age of 18 (except for the Flu and COVID vaccine)

  • Format: (000) 000-0000.

  • Patient's Doctor Information

  • Insurance Information

    (if you will be Self Paying, please email vax@sonapharmacy.com to discuss cost)

  •  Example Medicare Part B Card

  • Pharmacy Services Selection(s)

  • Select the vaccine(s) you would like to receive (vaccines listed with an * require a prescription)*

  • Please text the pharmacy at {pharmacyText} to confirm vaccine availability if scheduling within 24 hours of your requested appointment time

  • Please Answer the Below Questions

  • Healthcare provider recommended to receive a COVID vaccination
    Asthma
    Cancer
    Cerebrovascular disease
    Chronic kidney disease
    Bronchiectasi
    COPD
    Interstitial lung disease
    Pulmonary embolism
    Pulmonary hypertension
    Cirrhosis
    Non-alcoholic fatty liver disease
    Alcoholic liver disease
    Autoimmune hepatitis
    Cystic fibrosis
    Type 1 or Type 2 Diabetes
    Down Syndrome or other disabilities
    Epilepsy
    Heart conditions (such as heart failure, coronary artery disease, or cardiomyopathy)
    Hemophilia
    HIV
    Mood disorders (such as depression)
    Schizophrenia spectrum disorders
    Dementia
    Parkinson's Disease
    Overweight (BMI ≥ 25kg/m²)
    Physical inactivity
    Pregnancy or recent pregnancy
    Primary immunodeficiencies
    Sickle cell disease
    Former or current smoker
    Solid organ or blood stem cell transplantation
    Substance use disorders
    Use of corticosteroids or other immunosuppressive medications
    Tuberculosis

  • Is this your 1st or 2nd dose?
  • Do you have one of the following underlying conditions that prompted you to request a COVID vaccination?
  • Are you sick today?*
  • Do you have allergies to medications, food (e.g., eggs), yeast, a vaccine component, or latex?*
  • Have you ever had a serious reaction (including fainting) after receiving a vaccination?*
  • Has any physician or other healthcare professional ever cautioned or warned you about receiving certain vaccines or receiving vaccines outside a medical setting?*
  • Do you have a long-term health problem such as heart disease, lung disease, liver disease, asthma, kidney disease, metabolic disease (e.g., diabetes), anemia, or other blood disorder?*
  • Do you have cancer, leukemia, HIV/AIDS, or any other immune system problem?Have you been diagnosed with rheumatoid arthritis, ankylosing spondylitis, Crohn’s disease?*
  • In the past 3 months, have you taken medications that weaken your immune system, such as cortisone, prednisone, other steroids, or anticancer drugs, or have you had radiation treatments?*
  • Have you had a seizure or a brain or other nervous system problem or Guillain-Barré?*
  • During the past year, have you received a transfusion of blood or blood products, or been given immune (gamma) globulin or an antiviral drug?*
  • Have you received any vaccinations in the past 4 weeks?*
  • Are you pregnant or is there a chance you could become pregnant during the next month?*
  • Do you have a cut, injury, puncture, or open wound that prompted you to get a tetanus shot?*

  • A prescription is required for your tetanus vaccination from your provider.

     

  • Please Answer the Below Questions

  • Do you have any of these symptoms which are sometimes caused by the flu?
  • SymptomsNow
     - -
  • When did these symptoms start?
     - -
  • When were you exposed to a person with the flu?
     - -
  • Rows

  • Thank you for completing our questionnaire! Based on the information provided, we can provide testing as well as education about results and home self-care. However, we would not be able to prescribe a prescription for flu treatment.

  • Thank you for completing our questionnaire! Based on the information provided, we would not be able to prescribe a prescription for flu prevention.

  • (Parent or Guardian if patient is a minor)

  • Testing cost $50. Payment is due at check-in at the pharmacy.

  • POCT Symptons
  • When did symptons start?
     - -
  • Did you get your flu shot this year?*
  • Are you a smoker?*
  • Compared to others your age, how is your health?*
  • How would you describe your gender?*
  • Are you pregnant?*
  • Do you get medical treatment for any of the following health conditions? *Choose all that apply
  • Do you get treatment for any of the following mental health conditions? *Choose all that apply
  • How many different prescriptions and overthecounter medications do you take each day?*
  • In the past year, how may times have you stayed overnight as a patient in the hospital?*
  • In the past year, how may times have you stayed overnight as a patient in the hospital?*
  • In the past 6 months, how may times have you been a patient in an Emergency Room (ER)?*
  • Choose all services you have had in the past months
  • Do you need help with any of these activities? *Choose all that apply
  • Do you have the help you need with activities like bathing, eating or getting dressed?*
  • How often do you feel isolated from others?*
  • Over the last two weeks, how often have you been bothered by little interest or pleasure in doing things?*
  • Over the last two weeks, how often have you been feeling down, depressed or hopeless?*
  • In the past 12 months, did you worry that your food would run out before you got the money to buy more?*
  • In the past 12 months, did he food you bought just not last and you didn't have the money to get more?*
  • In the past 12 months, have you had a steady place to live?*
  • In the past 12 months, have you had trouble getting utilities when needed? Examples are heat, water and electricity.*
  • In the past 12 months, have you had trouble getting things you need because you didn't have a ride?*
  • Do you feel physically or emotionally unsafe where you live right now? Call local police if you need immediate help. *National Domestic Violence Hotline: 1-800-799-7233 or text the word START to 88788*
  • In the past 12 months, have you ben hit, slapped, kicked or physically hurt by anyone? *National Domestic Violence Hotline: 1-800-799-7233 or text the word START to 88788*
  • In the past 12 months, has anyone emotionally abused you? Examples are being bullied or intimidated. *National Domestic Violence Hotline: 1-800-799-7233 or text the word START to 88788*
  • Do you use tobacco products or vape?*
  • Has alcohol or drug use made it hard for you to work, keep relationships or meet goals?*
  • What is your race or ethnicity? *Choose all that apply*
  • Person Answering Relationship*
  • How would you describe your child's gender?*
  • Is your child pregnant?*
  • Does your child currently need or take medication prescribed by a doctor (other than vitamins)?*
  • Is this because of any medical, behavioral or other health conditions?*
  • Is this a condition that has lasted or is expected to last for at least 12 months?*
  • Does your child need or use more medical care, mental health or educational services than is usual for most children of the same age?*
  • Is this because of any medical, behavioral or other health conditions?*
  • Is this a condition that has lasted or is expected to last for at least 12 months?*
  • Is your child limited or unable to do the things most children of the same age can do?*
  • Is this because of any medical, behavioral or other health conditions?*
  • Is this a condition that has lasted or is expected to last for at least 12 months?*
  • Does your child need or get special therapy, such as physical, occupational or speech therapy?*
  • Is this because of any medical, behavioral or other health conditions?*
  • Is this a condition that has lasted or is expected to last for at least 12 months?*
  • Does your child have any kind of emotional, developmental or behavioral problem for which they need or get treatment or counseling?*
  • Is this a condition that has lasted or is expected to last for at least 12 months?*
  • Does your child get medical treatment for any of the following health conditions? *Choose all that apply
  • Does your child get treatment for any of the following mental health conditions? *Choose all that apply
  • Does your child have any of the follwing health conditions? *Choose all that apply
  • If your child has health problems, are you able to get the help you need caring for your child?*
  • In the past year, how many times has your child stayed overnight as a patient in the hospital*
  • In the past 6 months, how may times has your child been a patient in an Emergency Room?*
  • Choose all services your child has had in the past 12 months
  • How often does you rchild feel overwhelmed with stress or anxiety?*
  • Does your child do any of the following? *Choose all that apply
  • In the past 12 months, did you worry that your child's food would run out before you got the money to buy more?*
  • In the past 12 months, did the food you bought for your child just not last, and you didn't have the money to get more?*
  • In the past 12 months, has your child had a steady place to live*
  • Does your child feel physically or emotionally unsafe where they live right now?*
  • In the past 12 months, has your child been hit, slapped, kicked or physically hurt by someone? National Domestic Violence Hotline 1-800-799-7233 or text the word START to 88788*
  • In the past 12 months, has anyone emotionally abused your child? Examples are being bullied or intimated. National Domestic Violence Hotline 1-800-799-7233 or text the word START to 88788*
  • What is your child's race or ethnicity? *Choose all that apply
  • Careub Paid*
  • ARDWalkinApptDate
     - -
  • FVRWalkinApptDate
     - -
  • Current Date*
     - -
  • Should be Empty: