Free PCR Covid Saliva Test

Any tests peformed after 12 pm will be taken to the lab the following business day.

Our Address is 401 N Waco St

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. ***

**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.) Test times after 12 PM will go to the lab the following day.*
Full Legal Name*

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

Street Address

Street Address Line 2

CityState / 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)*

MonthDayYear
Date
Age*
Sex*

MaleFemaleOther
Ethnicity (this information is used to report testing statistics)

WhiteBlackAsianHispanic or LatinoNative Hawaiian or Other Pacific IslanderAmerican IndianMulti-RacialOther
Vaccination Status of Patient

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

First NameLast 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 exposureCoughShortness of breath or difficulty breathingFatigueHeadacheFever or ChillsMuscle or Body AchesNew Loss of Taste or SmellNausea or VomitingDiarrheaCongestion or Runny NoseSore ThroatNo Symptoms, but contact for 15 mins or more within 6 ft of a documented SARS-CoV-2 infectionSymptoms above and a confirmed contact with a confirmed case of COVID-19.
Date of Symptom Onset or Suspected Contact*

MonthDayYear
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?*

YesNo
**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:

**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 *