FREE COVID-19 Test Kit request form
Recipient Name
*
First Name
Middle Name
Last Name
Physical Address
*
Street Address
Apt #
City
State Initials
Zip Code
Date of Birth
*
/
Month
/
Day
Year
Gender
*
Male
Female
Email
*
example@example.com
Phone Number
*
Quantity requested
*
4
8
I prefer to
*
Pickup from Caplet pharmacy.
Get shipped at our home address.
Consent (check each box below after reading and prior to signing the form)
*
Rows
Check each box
I understand that I will be receiving the at home Covid-19 test at no cost to me. If Insured, I attest that I will provide my prescription or medical benefit information at the time of pickup. I am also authorizing the caplet pharmacy to bill my insurance for the test kits.
I have acknowledged that I have received the provider's Inc Notice
of Privacy Practices which may be provided at my request.
I agree that any tests purchased are either for the covered individual or their covered dependent, are not purchased to satisfy employment requirement, are not for resale and that the cost of the test is not being covered by any source other than sponsor.
Signature of Person to Receive Vaccine & EUA /VIS (or Signature of Parent/Guardian if Patient is < 18 years old):
Date Signed
/
Month
/
Day
Year
Date
Pharmacy Name
Pharmacy NPI
*
Submit Consent Form (required)
Should be Empty: