Free COVID Kit

First Name *

Last Name *

Medicare ID (xxxx-xxx-xxxx) *

Email Address *

Phone *

Date of Birth*

Select Gender

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Address *

Address Line 2

Country United States of America

Province * Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Lowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tenessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

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By submitting I give EXPRESS WRITTEN CONSENT authorizing PurePath Lab to be my preferred provider for my (8) OTC At-Home FDA Authorized, Covid-19 Tests each month (refilled monthly) for the duration of the Public Health Emergency (PHE). These tests are provided at no cost to me and are 100% covered by Medicare.