Required Documentation
In an attempt to reduce paper waste, all legally required documents must be downloaded here.
REQUIRED DOCUMENTS:
Please click to download the EUA for the tests we have available (you may receive one of the following):
Click here for the FlowFlex expiration date extensions from the FDA
All Patients
Click this to download the Notice of Privacy Practices
I understand the benefits and risks of the COVID-19 tests as described in the Emergency Use Authorization (EUA), a copy of which I was provided with this registration.
I understand the notice of Privacy Practices provides an explanation of the ways in which my health information may be used or disclosed by the pharmacy and of my rights with respect to my health information. I have been provided with the opportunity to discuss concerns I may have regarding the privacy of my health information.
I certify that I have received, read, and understand the Emergency Use Authorization.
I certifty that I have received the Notice of Privacy Practices.
I am requesting 8 (or third party allowable quantity) of At-Home COVID-19 tests for personal use.
Please type your full name in the box below. Your typed full name represents your electronic signature is the legal equivalent of your manual signature on this form.