groveway LF

1
Hello, what is your name?* This field is required.
First Name
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2
What is your best phone number?* This field is required.
Please enter a valid phone number.
3
What is your best email?* This field is required.
example@example.com
4
What is your date of birth?* This field is required.
Date
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Day
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5
What is your Gender* This field is required.
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6
What address do you want your test kits sent to?* This field is required.
Street Address
Street Address Line 2
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7
Image Field
8
Please Enter Your Medicare ID (i.e 1EG4-TE5-MK72)* This field is required.
9
TERMS AND CONDITIONS* This field is required.Notice of HIPAA Privacy Policy, Advanced Beneficiary Notice of Non-Coverage (ABN) and Terms and Conditions. By submitting I give Express Written Consent authorizing Groveway Pharmacy to be my preferred provider for my 8 at home, Covid-19 tests each month for the duration of the Public Health Emergency (PHE). These tests are provided at no cost and are 100% covered Medicare. I understand Medicare will only pay for 8 COVID-19 tests per calendar month
I agree to Terms and Conditions.
10
How many COVID-19 tests would you like* This field is required.
8 Free Tests
2 Free Tests
4 Free Tests
6 Free Tests
11
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