Free PCR Covid Saliva Test

Due to extremely high demand, please do not call the pharmacy. We are doing our best to keep up with prescriptions, vaccines, and testing. We greatly appreciate your patience and understanding. 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**

Quidel QuickVue at home OTC Covid 19 2 pack Test Kits are available for purchase in the store.
**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
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 *

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

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
Appointment Time *
**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) is 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 to the number provided at registration. *

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**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 *