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**
Basic Demographic Information
Appointment
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
Cash Payment

To pay with cash please leave the below field blank.
My Products
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Rapid Test Rapid test is $95 plus tax
$ 95.00

PCR PCR test is $150 plus tax. Results can take up to 72 hours to get back to our pharmacy.
$ 150.00

Subtotal

$ 0.00

Tax

$ 0.00

Total

$ 0.00

Payment Methods

Debit or Credit Card

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

Basic Demographic Information