COVID-19 Rapid Antigen Test Screening
Due to the high demand of testing and increased exposure, we are updating our testing procedure to require pre-payment via card or PayPal. NO REFUNDS will be given for cancellations or rescheduling due to high demand. Please pay close attention to the day and time of your appointment. Text 316.348.8517 upon arrival and wait in the designated parking area. Thank you for helping us keep our patients and staff safe and healthy.
Full Legal Name
Address (PO Box is not acceptable, must have a physical address)
Street Address Line 2
State / Province
Postal / Zip Code
County of Residence (SG, KM, RN, BU, HV, etc)
Cell Phone Number
Date of Birth
Ethnicity (this information is used to report testing statistics)
Hispanic or Latino
Native Hawaiian or Other Pacific Islander
Primary Care Provider (Doctor)
Primary Care Provider (Doctor) Location City/State
Check any of the following symptoms you are currently experiencing:
Shortness of breath or difficulty breathing
Fever or Chills
Muscle or Body Aches
New Loss of Taste or Smell
Nausea or Vomiting
Congestion or Runny Nose
No Symptoms, but contact for 15 mins or more within 6 ft of a documented SARS-CoV-2 infection
Symptoms above and a confirmed contact with a confirmed case of COVID-19.
Date of Symptom Onset or Suspected Contact
Have you traveled outside of Kansas in the last 1-2 months? Where did you go?
Reason for requesting test:
Who referred you to us for testing?
If your employer is paying for this test, please put their name in comments below and check this box.
Please list the name of anyone who has helped you complete this form:
By signing below, you agree that your answers are true and accurate to the best of your ability, you will read the handout provided at the time of testing and you authorize Professional Pharmacy to release the results of your test to your primary provider. Your signature below indicates that you have been informed that we are unable to bill insurance for this test and you authorize the payment below. Additionally, you authorize the use of this electronic form and signature and understand there are no refunds or reschedules available after this form is submitted..
( X )
Rapid Covid Antigen Test
One rapid covid antigen test, prepaid booking. No refunds. One form and appointment per person being tested.
Credit Card Number
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