Request for FREE At-Home Covid Tests

NC MEDICAID Request for FREE At-Home Covid Tests

****NC MEDICAID COVERS 8 tests per month. Other insurances are no longer covering the tests. We do have free tests that can be picked up at our pharmacy. My Pharmacy 2525A Phillips Ave Greensboro, NC 27405
Name (as it appears on insurance card)*

First NameLast Name
Phone Number
Please enter a valid phone number.
Date of Birth*

MonthDayYear
Date
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Send me more tests for the next ___ months*

No thanks36Until I cancel
Do you want these delivered for FREE?*

YesNo
Signature*
If you have Medicare, please provide your Medicare ID number off your red, white, and blue card or the last 4 digits of your social security number.
Please fill out the name and date of birth for other family members to request tests.
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Thank you for your covid19 test kit order. We'll have these delivered to you within a few days. If you reside outside of our delivery radius, we'll mail them to you at no charge. Thanks for supporting your local, independently owned pharmacy.

**Ask us about our on-site flu shot clinics!**
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NC MEDICAID Request for FREE At-Home Covid Tests