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COVID-19 Rapid Antibody Testing
Due to the high demand of testing and increased exposure, we are updating our testing procedure to require pre-payment via card. 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
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First Name
Last Name
Address (PO Box is not acceptable, must have a physical address)
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
County of Residence (SG, KM, RN, BU, HV, etc)
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Cell Phone Number
*
-
Area Code
Phone Number
Email
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example@example.com
Date of Birth
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Month
-
Day
Year
Date
Age
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Sex
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Male
Female
Ethnicity (this information is used to report testing statistics)
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White
Black
Asian
Hispanic or Latino
Native Hawaiian or Other Pacific Islander
American Indian
Multi-Racial
Date of Confirmed or Suspected Covid Infection
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-
Month
-
Day
Year
Date
Appointment Time
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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..
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Antibody IgG/IgM Test
$
25.00
1 antibody test
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