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  • iPack Rx: Flowflex Request Form

    iPack Pharmacy Ph: 262-649-3900
  • Patient Information

  • Attestation

    By submitting this form I have requested the pharmacy to provide the listed OTC COVID-19 tests and attest to the following. The tests requested above are for personal use for the indicated patient. These tests are not for employer or travel purposes. I agree not to resale the tests provided under this covered benefit. The cost of these tests is not being covered by any other source. I have not requested OTC COVID-19 tests from another provider in the current calendar month. Subject to availability. Limit 8 test kits per month.
  • Pick up test kits at iPack Pharmacy Mon-Fri 9am-6pm

    17000 W North Ave Suite 108W Brookfield, WI 53005
  • Should be Empty: