Free Covid Tests

Free Covid Tests

Please fill out the form below to receive your free Covid tests. The tests will be at no cost to you either for billing or delivery.
Name*

First NameLast Name
Birth Date *

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
How would you like to get your tests?*

DeliveryPick-up
Signature*

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I acknowledge I am allowed to get 8 tests per month without any cost to me directly. I allow Parkway Pharmacy to bill my insurance to cover the cost of the at-home rapid covid test kits. By signing above, the patient is attesting: The tests are for personal use for indicated patient(s) on the form, the tests are not for employer or travel purposes, the tests are not for children < 2 years old, the patient will not resell the tests provided under their benefit, the cost of the tests is not being covered by any other source. The patient has not requested OTC COVID-19 tests from any other provider in the current calendar month.
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