COVID-19 Antigen Self Test Kit Request Form

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Thanks to support from Maine Department of Health and Human Services, Healthy Acadia has a limited* number of COVID-19 Antigen Self Test Kits available to help reduce the spread of COVID-19. Upon request, Washington and Hancock County residents may request 1 testing kit (2 tests) per person by completing and submitting this form. Your test kit will be mailed to you by U.S.postal mail or set up for pick up at INSPIRE Recovery Center in Ellsworth or at Healthy Acadia office, Machias. If it is being mailed, please provide your complete shipping address below to ensure proper delivery of your test kits.

NOTE: Supplies are limited - requests will be filled in the order received and while supplies last.

Your First Name *

2. Your Last Name *

3. What county do you live in? *

Washington

Hancock

Other

4. Please select your reason(s) for requesting a test kit *

I have one or more symptoms of COVID-19.

I am a close contact of someone who recently tested positive. (If you know you have been exposed to COVID-19, the Food and Drug Administration (FDA) recommends testing 3 to 5 days after exposure.)

I will be attending a gathering with people who do not live with me. (The best time to test is the same day you want to know if you have COVID. Test on the day, or as close as possible to the day of your planned gathering.)

Other:

Required

6. How would you like to receive your test? *

Pick up in person - please provide your phone number in Question 7.

By mail - please provide your complete mailing address in Questions 8-10.

7. If you plan to pick up a test kit in person, please provide a phone number where you can be reached during the day. A member of our team will contact you to arrange a pickup time and location.

If you would like to receive a test kit by mail, please complete Questions 8 through 10 below. IMPORTANT. The test kit and all components must be kept at temperatures above freezing at all times. If no one is available at your mailing address to bring the test kit indoors immediately upon delivery, please select the pick up in person option in Question 6 and enter a phone number in Question 7. A member of our team will contact you to arrange a pickup time and location.

8. Your mailing address (physical street address or P.O. box).

9. Your city or town

10. Your zip code

11. If you are having the kit mailed, a phone number in case of any questions.

Can you help make this service available on an ongoing basis? Donations are gratefully accepted!

Can you help make this service available on an ongoing basis? Your donation in any amount will enable Healthy Acadia to continue to provide free-of-charge COVID-19 rapid antigen self test kits to residents in Hancock and Washington counties beyond the program's initial grant funding, which is rapidly running out. Donations are accepted at bit.ly/HACovidtest. To discuss further ways to support this effort, call 207-667-7171 ext. 210. Thank you for building COVID-19 safety supports with Healthy Acadia!

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