First Name

Street Address

State

Zip Code

Date of Birth (MM/DD/YYYY)

Gender

Mobile Number

Email Address

Would You Like Us To Automatically Send Your Kits Each Month

By submitting, I give EXPRESS WRITTEN CONSENT authorizing Precision Rx Pharmacy to be my preferred provider for my 8 OTC Covid tests and to refill my monthly order on the 1st of every calendar month. Also, I give permission to Precision Rx Pharmacy to contact me at the phone number above in regard to other healthcare benefits or billing questions.