Gates Pharmacy - Request for FREE At-Home Covid Tests (covered by most insurances)

Request for At-Home COVID Tests (covered by most insurances)

Most insurances cover 4-8 tests per month with no copay. Gates Pharmacy -- 364 N South St. Mount Airy, NC 27030
Name (as it appears on insurance card)*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Date of Birth*

MonthDayYear
Date
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Send me more tests for the next ____ months*

No Thanks1236
Do you want these delivered for FREE?*

YesNo
How many At-Home Tests would you like to receive?*
(most insurances allow up to 8 tests per month)
How many At-Home Tests do you currently have?*
Signature*

Clear
If you have Medicare, please provide your Medicare ID number off your red, white, and blue card or the last 4 digits of your social security number.
To request tests for other family members, please provide name and date of birth
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Thank you for your Covid-19 test kit order. We'll have these delivered to you within a few days. If you reside outside of our delivery radius, we'll mail them to you at no charge. Thanks for supporting your local, family owned pharmacy.
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Request for At-Home COVID Tests (covered by most insurances)