Free At Home Covid Tests
Take a free COVID-19 home test! Many insurance plans will cover COVID-19 home tests at no cost to you. Once you fill out the form below, we’ll prepare your order as timely as possible and contact you by phone. Quantities of tests distributed are subject to insurance and inventory limitations. Typical monthly allowed amounts allowed are: 8 home tests for Medicare and commercial patients, and 2 tests for Missouri Medicaid patients. Tests can be ordered monthly. Contact us with any questions at (417) 451-9501 or firstname.lastname@example.org
Street Address Line 2
State / Province
Postal / Zip Code
Do you have any known medication allergies?
Please list them.
Do you live in Missouri? (Must be a Missouri Resident)
What is your preferred delivery method?
Store pick up (Boulevard store)
If these tests are not covered by your insurance plan, how many would you like to pay for?
1 for $18
2 for $30
3 for $42
4 for $55
If insurance does not cover covid tests, I don't want any (you won't hear from us)
We are happy to offer free delivery for home tests to places of business and facilities with multiple orders. Please let us know if you'd like this accommodation (May ignore if not applicable) (Yes/No)
I have read the attestation below and am requesting these covid tests. (Type name)
Insurance information is required for free at home covid tests. If we have your insurance on file already, skip this section. If we don't have your insurance on file, please answer the following questions:
Do we have your updated insurance information at our pharmacy?
Insurance Cardholder ID:
Insurance group #:
Do you have Medicare?
Medicare Part B (Red white and blue card) number:
Should be Empty:
Now create your own Jotform - It's free!
Create your own Jotform