Covid-19 Rapid Test Form

88 East Main Road. Middletown, RI

401-619-5020

Please stay in your vehicle and call when you arrive.
(COVID-19) Rapid Test Application $95 +tax
RI State Requirements

We are obligated to collect specific data and submit results to the State for accurate testing results.
Patient Information--**Applicant or Parent must provide Driver’s License**
Appointment : Currently Booking Mon/Tue/Wed/Thur/Fri/Sat/Sun *
Basic Demographic Information
Name *

First Name Last Name
Date of Birth: *

Month Day Year
Date
Race (check all that apply) *

Black of African American White Asian Native Hawaiian of Other Pacific Islander Other
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 :

Month Day Year
Date
Signature of person who completed application *

Sign with finger if using smart phone/ mouse if on computer Clear
Should be Empty:

Basic Demographic Information