At-home COVID-19 Test Request Form

Please complete one form per each member’s request.

*This form is only to be used by members of the Kettering Health Prescription Benefit Plan. For other inquiries please contact the pharmacy directly.

"*" indicates required fields

Name*

First Last

Date of Birth*

Insurance Subscriber ID*

* Please complete one form per each member request

Home Phone

Cell Phone

Email*

Address*

Street Address City State / Province / Region ZIP / Postal Code

Quantity of COVID-19 Tests (Max 8/month)

Your Pharmacy Location*

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