Covid Test KIT Form

Patient Request and Attestation for COVID-19 Over the Counter Tests
Date Requested

MonthDayYear
Date
Patient Name *

First NameLast Name
Patient Date of Birth*

MonthDayYear
Date
Person Requesting ( if different from Patient Name)
Ship to Address*

Street Address

Street Address Line 2

CityState

Zip Code
Mobile Number*
Quantity of Test Requested (max of 8 tests per month depending on insurance)*
I have requested the pharmacy to provide the above listed OTC COVID-19 tests and attest to the following:
- The tests requested above are for personal use for the indicated patient(s)
- These tests are not for employer or travel purposes
- I agree to not resale the tests provided under this covered benefit
- The cost of these tests is not being covered by any other source
Signature of Patient ( or legal representative)

Clear
Today Date

MonthDayYear
Date
Should be Empty: