AT-Home COVID-19 Test Request Form
Thank you for choosing Kollhoff Pharmacy!
Please enter information below to request COVID-19 tests
Name
*
First Name
Last Name
Birth Day
*
-
Month
-
Day
Year
Cardholder Name
*
First Name
Last Name
Cardholder Birth Day
*
-
Month
-
Day
Year
Phone Number
*
-
Area Code
Phone Number
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
Number of tests requested (most insurance allows 8 per month)
*
2
4
6
8
Please upload a picture of your insurance card below
Required information includes ID number, Rx BIN, Rx Group, Rx PCN **Tricare does not participate**
*
Browse Files
Cancel
of
Please contact me when my tests are ready
*
phone call
text
Signature
*
Clear
Submit
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