Kirk's Pharmacy COVID-19 Screening and Testing Form
Patient Full Name *
Date of Birth (TEST RECIPIENT MUST BE 16 YEARS OR OLDER) *
MM
/
DD
/
YYYY
Sex *
Required
Address *
Zip Code *
Email *
Phone *
Primary Care Provider and Contact *
***If you do not have a PCP, just mark N/A - this will not impact your ability to recieve a test kit***
Race (Check all that Apply) *
Required
Ethnicity *
Required
Are you experiencing COVID-19 symptoms? *
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