COVID-19 Rapid Test Appointment

COVID-19 Rapid Test Appointment

Free COVID-19 tests available to all Kansas residents. Not available for out-of-state residents.
BinaxNOW rapid tests produce results 15 minutes after collecting the sample. The sample is collected by inserting a nasal swab 1/2 - 3/4 inch into each nostril and swabbing for 15 seconds.

DO NOT COME IN THE PHARMACY FOR A COVID-19 TEST.

Park in our parking lot and give us a call when you arrive: 913-837-3784. We will come to you car to do the test. Thank you!
Appointment *
Name *

First Name Last Name
Date of Birth *

Month Day Year
Date
Race *
Ethnicity *
Gender *
Name of legal guardian if patient is under 18

First Name Last Name
Date of birth of legal guardian if patient is under 18

Month Day Year
Date
Phone Number - Use a phone number that receives text messages. The lab will text you a link to your results using this phone number. *
Please enter a valid phone number.
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Email - not required; only if you would like the test result like emailed to you.
example@example.com

Test screening questions *

	Yes	No	Unknown
Is this the patient's first COVID-19 test?
Is the patient employed in healthcare?
Does the patient have symptoms of COVID-19?
Is the patient a resident in a congregate care setting? (Group living environment)
Is the patient pregnant?
Has the patient had a known exposure to COVID-19?
Is the patient fully vaccinated for COVID-19?

What symptoms does the patient have? (If none, please type in "none.") *
What date did symptoms start?

Month Day Year
Date
If the patient has been full vaccinated, select the date of the most recent COVID-19 vaccination.

Month Day Year
Date
Signature

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