Paxlovid Request - Active Covid Form Logo

  • Have Active Covid? PAXLOVID REQUEST

    If you have an ACTIVE COVID-19 Infection, please let us help you get the appropriate medications for you. To qualify, you can get FREE Paxlovid (whether you have insurance or not). We can assist with other items as well and we can deliver to you or you can pick up through our drive thru. It will take approximately 3 minutes to fill these forms.

  • There is no cost associated with this if you fill this form.  To best assist you, fill this form to the best of your knowledge. This form makes it easier for the pharmacist to review your profile and our team to provide you the appropriate medications.

    Alternatively, you may schedule a virtual appointment with our clinical pharmacist for a $30 consult fee.  Go under the SCHEDULE A VACCINE button on www.midrx.com, Select PAXLOVID REQUEST APPOINTMENT.  Then select any appropriate time slot and the pharmacist will call you at the number you requested. Alternately, you can call 817-605-3500 at that time. 

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  • MEDICAL ELIGIBILITY

    Here, we will ask multiple questions to document if you are the right candidate for Paxlovid and / or other types of treatments and programs. You acknowledge that the information you enter is correct to the best of your knowledge.

  • We care about you and your health!

    We have helped treat thousands of patients with active COVID infection. We have multiple recommendations that will potentially help your body heal faster. We have the following recommendations. We can also provide you different infection protocols at no additional cost.
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  • Last question!

    Okay. We have most, if not all of the information to help you. Once you submit, we will start working on this for you and text you. You can also call us but give us time to process your prescription as we have other patients we likely working on or we are closed at this moment.
  • Clear

  • PRESS SUBMIT TO SEND THE INFORMATION TO OUR PHARMACIST

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