OTC COVID 19 Test Request

Patient Request and Attestation for COVID-19 Over the Counter Tests
Date Requested

MonthDayYear
Date
Online
Patient Name (Last Name, First Name)*
Patient Date of Birth*

MonthDayYear
Date
Person Requesting (if different from Patient Name)
Ship to Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mobile Number
Please enter a valid phone number.Format: (000) 000-0000.
Quantity of Test Requested (max of 8 tests per month depending on insurance)*
I have requested the pharmacy to provide the above listed OTC COVID-19 tests and attest to the following:
- The tests requested above are for personal use for the indicated patient(s)
- These tests are not for employer or travel purposes
- I agree to not resale the tests provided under this covered benefit
- The cost of these tests is not being covered by any other source
All orders for tests will be shipped in 1-2 business days
Signature of patient (or legal representative)

Clear
Today Date

MonthDayYear
Date
Pharmacy Name
Pharmacy NPI
Should be Empty:

All orders for tests will be shipped in 1-2 business days