Flowflex Request Form

iPack Rx: Flowflex Request Form

iPack Pharmacy Ph: 262-649-3900
Patient Information
Patient Name*

First NameLast Name
Patient Birth Date*

MonthDayYear
Patient Phone*
Please enter a valid phone number.
How many test kits are you requesting
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
How to test using Flowflex COVID-19 Antigen Home Test
Should be Empty:

iPack Rx: Flowflex Request Form