Covid-19 Test Form

Matt's Local Pharmacy is offering both rapid antigen tests and rapid PCR tests for covid-19.
- A rapid antigen test costs $95 plus tax
- A rapid PCR test costs $175 plus tax
- Results will be available in less than one hour*
- All tests will be conducted by our staff member at your vehicle in our parking lot.
- Our test results are performed under CLIA compliance and meet official requirements for proof-of-negative-status for travel, medical appointments, summer camp, etc.
- We ask that you stay in your vehicle and call us at 401-619-5020 to notify us that you have arrived.
We look forward to testing you and helping to keep our community safe and healthy this winter!

*We will contact you by phone when we have your test results and will email your test results to the email address you provide below.
RI State Requirements

We are obligated to collect specific data and submit results to the State for accurate testing results.
Basic Demographic Information
Appointment*
Name*

First Name Last Name
Date of Birth:*

MonthDay Year
Date
Race (check all that apply)*

Black or African AmericanWhiteAsianNative Hawaiian of Other Pacific IslanderOther
Gender:*
Phone Number*

Area Code Phone Number
Address*

Physical/Street Address (P.O. Box is NOT accepted)

Street Address Line 2

City State / Province

Zip
Primary Care Provider Name: *
Primary Care Provider Phone Number*

Area Code Phone Number
Do you currently use Matt's Local Pharmacy for your prescriptions?*
Email*
example@example.com
If the patient is under 18 years, name of parent/guardian:
Date of onset symptoms :

MonthDay Year
Date
Signature of person who completed application*

Sign with finger if using smart phone/ mouse if on computer Clear
Cash Payment

To pay with cash at the pharmacy, please leave the below field blank.
Which test(s) would you like to receive with us?*

Rapid antigen test ($95 plus tax)Rapid PCR test ($175 plus tax)Rapid antigen test AND flu test ($100 plus tax)Rapid PCR test ($180 plus tax)
My Products
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Rapid Covid-19 Test Rapid test is $95 plus tax. Our pharmacy staff will call you with your antigen rapid test result in less than one hour.
$95.00



PCR Covid-19 TestPCR test is $175 plus tax. Our pharmacy staff will call you with your PCR test results in 90 minutes or less PCR tests are conducted in house
$175.00



Add on a flu (influenza A & B) for $20.00Add on a flu test to you covid-19 antigen or PCR test for an additional $20.00 plus tax (this is only for patients receiving a covid-19 test). Our pharmacy staff will call you with your covid-19 and flu test results in less than one hour.
$20.00



Subtotal

$0.00

Tax

$0.00

Total

$0.00
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Payment Methods

Debit or Credit Card

First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Please click one of the PayPal options to complete payment and submit the form.

Should be Empty:

RI State Requirements

Basic Demographic Information

Cash Payment