Refill Prescription – Welcome to RXCare

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Pre Registration Form

Please fill in the details below.

Kindly be ready with scanned copy of your insurance card or Driving License or State Id Card before starting the pre registration process. This registration form is not an appointment confirmation. Individual Pharmacy testing dates and times vary. Please book your appointment directly with your pharmacy.

Patient Information

Name *

DOB *

Email Id *

Phone Number *

Gender *

Race *

Ethnicity *

Address *

Testing Information

State *

Select City, Pharmacy & Location *

Select Test *

Day for test *

Time for test *

Select from the COVID-19 codes & symptoms

Insurance Information

Please upload a valid JPG, JPEG or PNG image format with recommended dimension 900X675

Insurance Image

Type of Identification *

Identification Image *

IMPORTANT: Please bring your health insurance card, a copy of the physician requisition and State ID at the time of your appointment.

I authorize RxCare Pharmacies to contact me and understand that I may opt out at any time.

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Required Information

Who is this prescription for?

RX REFILL NUMBERS

ADD MORE PRESCRIPTION

Name

Qty

Pick Up Or Delivery

Pre Registration Form

Please upload a valid JPG, JPEG or PNG image format with recommended dimension 900X675

Enter your keyword

Required Information

Who is this prescription for?

RX REFILL NUMBERS

ADD MORE PRESCRIPTION

Name

Qty

Pick Up Or Delivery

Thank You

Pre Registration Form

Please upload a valid JPG, JPEG or PNG image format with recommended dimension 900X675