Rapid PCR Covid-19 Test Form

Rapid PCR Test for Covid-19.
- A rapid PCR test costs $99 plus tax
- Results will be available in less than one hour*
- All tests will be conducted by our staff member at your vehicle in our parking lot.
- Our test results are performed under CLIA compliance and meet official requirements for proof-of-negative-status for travel, medical appointments, summer camp, etc.
- We ask that you stay in your vehicle and call us at 401-619-5020 to notify us that you have arrived.
We look forward to testing you and helping to keep our community safe and healthy this winter!

*We will contact you by phone when we have your test results and will email your test results to the email address you provide below.
RI State Requirements

We are obligated to collect specific data and submit results to the State for accurate testing results.
Basic Demographic Information
Appointment*
Name*

First NameLast Name
Date of Birth:*

MonthDayYear
Date
Race (check all that apply)*

Black or African AmericanWhiteAsianNative Hawaiian of Other Pacific IslanderOther
Gender:*
Phone Number*

Area CodePhone Number
Address*

Physical/Street Address (P.O. Box is NOT accepted)

Street Address Line 2

CityState / Province

Zip
Primary Care Provider Name: *
Primary Care Provider Phone Number*

Area CodePhone Number
Do you currently use Matt's Local Pharmacy for your prescriptions?*
Email*
example@example.com
If the patient is under 18 years, name of parent/guardian:
Date of onset symptoms :

MonthDayYear
Date
Signature of person who completed application*

Clear
Sign with finger if using smart phone/ mouse if on computer
Cash Payment

To pay with cash at the pharmacy, please leave the below field blank.
Which test(s) would you like to receive with us?*

Rapid PCR test ($99 plus tax)
My Products
prevnext( X )
PCR Covid-19 TestPCR test is $99 plus tax. Our pharmacy staff will call you with your PCR test results in 90 minutes or less PCR tests are conducted in house
$99.00

Subtotal

$0.00

Tax

$0.00

Total

$0.00
Type a question
PDF to be Sent

Yes

Payment Methods

Debit or Credit Card

Please click one of the PayPal options to complete payment and submit the form.

Should be Empty:

RI State Requirements

Basic Demographic Information

Cash Payment