Free PCR Covid Saliva Test

OTC Antigen Tests are available in limited supplies in store, Ihealth 2 packs $27.99

If you would, please TEXT us at 316-348-8517 with your name, parking location, vehicle and test time, we will meet you at your vehicle.

Please DO NOT enter the pharmacy.

Any tests peformed after 3 pm may go to the lab on the next business day. We are to advise that results will be available within 48 hours. **YOU NEED TO RETAIN THE EMAIL USED ON YOUR FORM AND PIN # TO ACQUIRE RESULTS**
**PLEASE NOTE THAT YOU MAY NOT EAT, DRINK, SMOKE, OR BRUSH 30 MINUTES PRIOR TO YOUR SALIVA COLLECTION ***

FREE COVID-19 Saliva Specimen Test Screening in Collaboration with WSU MDL
Appointment Time (Appts are only open 3 business days in advance due to supply limits and increased demand. If there are no times available to choose, we are booked up.) *
Full Legal Name *

First Name Last Name
4 digit PIN Number for Results *
Address (PO Box is not acceptable, must have a physical address) *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
County of Residence (SG, KM, RN, BU, HV, etc) *
Cell Phone Number *
Email *
example@example.com
Date of Birth (PLEASE VERIFY FOR ACCURACY) *

Month Day Year
Date
Age *
Sex *

Male Female Other
Ethnicity (this information is used to report testing statistics)

White Black Asian Hispanic or Latino Native Hawaiian or Other Pacific Islander American Indian Multi-Racial Other
Vaccination Status of Patient

Fully Vaccinated and Boosted Yes (fully vaccinated with all required doses) No (no doses received) In Progress (received one, but not all required doses)
Primary Care Provider (Doctor)

First Name Last Name
Primary Care Provider (Doctor) Location Address, City/State
City/State
Check any of the following symptoms you are currently experiencing: *

No symptoms, no known exposure Cough Shortness of breath or difficulty breathing Fatigue Headache Fever or Chills Muscle or Body Aches New Loss of Taste or Smell Nausea or Vomiting Diarrhea Congestion or Runny Nose Sore Throat 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 *

Month Day Year
Date
Please list the name of anyone who has helped you complete this form:
Comments/Concerns:
Are you requesting this test in advance of travel or for proof of non-infection for an airline, or destination? *

Yes No
**YOU UNDERSTAND THAT YOU MAY NOT EAT, DRINK, SMOKE, OR BRUSH YOUR TEETH 30 MINUTES PRIOR TO COLLECTION OF YOUR SALIVA. You also understand that you (the patient) are responsible for ensuring this test meets the requirements of any third party testing requests of airlines/destinations/etc. By signing below, you agree to the release and consent listed throughout this form and agree that your results may be provided via automated telephone call or text message to the number provided at registration; however, you should retain your pin and email to access your testing results via email. *

Clear
Should be Empty:

Now create your own Jotform - It's free! Create your own Jotform

**PLEASE NOTE THAT YOU MAY NOT EAT, DRINK, SMOKE, OR BRUSH 30 MINUTES PRIOR TO YOUR SALIVA COLLECTION ***

PLEASE NOTE THAT YOU MAY NOT EAT, DRINK, SMOKE, OR BRUSH 30 MINUTES PRIOR TO YOUR SALIVA COLLECTION *