Home Test Kits: Order Form

At-Home COVID-19 Test

Please use this form to order your at-home COVID-19 test kit. You may order multiple kits shipping to one address. If you are looking to ship kits to different addresses, please fill out a new form for each shipping address.
Name*

First NameLast Name
Email*
example@example.com
Phone Number (for any FedEx delivery issues)*
Format: (000) 000-0000.
Shipping Address (no P.O. Boxes)*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Please select the test type and quantity of kits you would like to receive:*

Antigen Kit with Supervised Testing via Telehealth

Includes one antigen test, one supervised telehealth session, and one official test report that meets return-to-work clearance. For patients who test positive, a Paxlovid consultation is included and qualified patients will receive a Paxlovid prescription.

$60.00 Quantity

At-Home Lab PCR Kit

Includes one Lab RT-PCR test, FedEx overnight return shipping to the lab, and an official Lab RT-PCR test report.

$150.00 Quantity

At-Home Lab RT-PCR Kit with Supervised Testing via Telehealth

Includes one Lab RT-PCR test, one supervised telehealth session, FedEx overnight return shipping to the lab, and an official Lab RT-PCR test report.

$175.00 Quantity

Total

$0.00

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Should be Empty:

At-Home COVID-19 Test