At-Home COVID TESTS

1
Patient Name* This field is required.
First Name
Middle Initial
Last Name
2
Date of Birth* This field is required.MM-DD-YYYY
3
Cell Phone* This field is required.
4
Gender* This field is required.
5
Email* This field is required.Needed if you need the results emailed to you
example@example.com
6
Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
7
Please fill out the following insurance information from your insurance card.Please use the information from your prescription RX card (not your medical card). If you are 65+ or have a Medicare B (red, white and blue card), please leave this section blank.
RX Bin
8
Please fill out the following insurance information from your insurance card.Please use the information from your prescription RX card (not your medical card). If you are 65+ or have a Medicare B (red, white and blue card), please leave this section blank.
RX PCN
9
Please fill out the following insurance information from your insurance card.Please use the information from your prescription RX card (not your medical card). If you are 65+ or have a Medicare B (red, white and blue card), please leave this section blank.
RX Group
10
Please fill out the following insurance information from your insurance card.Please use the information from your prescription RX card (not your medical card). If you are 65+ or have a Medicare B (red, white and blue card), please leave this section blank.
ID Number
11
Please fill out the following insurance information from your Medicare B insurance card.If you are 65+ or have a Medicare B (red, white and blue card) type in the ID number below. Leave all above fields blank.
ID Number
12
Please upload a copy of your RX insurance card. If you are 65+ and have a Medicare B card (red, white, and blue card), we will need that card.* This field is required.If you cannot do this, click NEXT, we will reach out to you if the information provided in the insurance section does not work.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
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13
How Would You Like The Tests?* This field is required.
Please deliver to my house.
I will pick up from the pharmacy.
14
Signature* This field is required.I acknowledge I am allowed to get up to 8 tests per month from my insurance without any cost to me directly. I allow Pharmacy Town to bill my insurance company to cover the cost of the at-home rapid covid test kits. By submitting this form, I acknowledge that this is a request and that if my insurance does not cover the tests, I will be notified accordingly.
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