COVID 19 RAPID ANTIGEN TEST FORM

COVID 19 Drive-Thru Testing Service

Complete the Form Below. Testing will end at 5:15 PM Daily.
*DO NOT ENTER THE PHARMACY FOR TESTING*
INSTRUCTIONS

1. Complete this Form. Each form is for one individual. If you have more that one person testing - you will need to do multiple forms.

2. Drive to Pharmacy Curb-Side

3. Please wear a mask at arrival and wait for representative to come out for testing.

4. We do NOT accept health insurance for any of our services. Please call the number on the back of your insurance card for a network provider in your health plan.

5. We do accept Health Savings Account (HSA) and Flexible Spending Account (FSA) cards and we do provide itemized receipts for our services.
Select Test Type

RT-PCR Test - $125.00Rapid Antigen Test (Nasal) - $99.00
Name*

First NameLast Name
Date of Birth (MM/DD/YYYY)*
Gender*

MaleFemaleI prefer not to say
Phone Number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState

Zip Code
E-mail
example@example.com
Identification

Please provide a copy of your identification. You may either take a photo or upload a copy.
Upload a copy/photo of your Drivers License or Identification

Cancelof
Take a photo of your Drivers License or Identification
Spencer’s Prescription Pharmacy is not responsible for any representations. Please check with your end-user to make sure they accept a Rapid Antigen Test.
Please sign to agree.

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COVID 19 Drive-Thru Testing Service