FREE Nasal Rapid Antigen

Please note that we have moved to 401 N Waco St as of August 1st

PLEASE TEXT US AT 316-348-8517 IF YOU MUST CANCEL.

Please be prepared to blow your nose when you arrive by bringing a tissue. We will need you to do so before administering the test. Please read the Patient Fact Sheet.
Please select an appointment time: (If there are no times available, we are booked up. Due to product availability we only allow scheduling out 3 days in advance.) *
Patient Date of Birth *

Month Day Year
Date
Patient Full Legal Name *

First Name Last Name
LEGAL Guardian Name (required by the state)

First Name Last Name
LEGAL Guardian Date of Birth (required by the state)

Month Day Year
Date
Address (PO Box is not acceptable, must have a physical address) *

Street Address

Street Address Line 2

City State

Zip Code
County of Residence (SG, KM, RN, BU, HV, etc) *
Cell Phone Number *
Email *
example@example.com
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
Your signature certifies that you understand: 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 to the number provided on this registration form. You have read the Fact Sheet for this test above. INFORMED CONSENT FOR COVID-19 TESTING 1. Authorization and Consent for COVID-19 Diagnostic Testing: • I voluntarily consent and authorize the Kansas Department of Health and Environment (“KDHE”) to conduct collection, testing, and analysis for the purposes of a COVID-19 diagnostic test. • I acknowledge and understand that my COVID-19 diagnostic test will require the collection of an appropriate sample through a nasopharyngeal swab, oral swab, or other recommended collection procedures. • I understand that there are risks and benefits associated with undergoing a diagnostic test for COVID-19 and there may be a potential for false positive or false negative test results. • I assume complete and full responsibility to take appropriate action with regards to my test results. Should I have questions or concerns regarding my results, or a worsening of my condition, I shall promptly seek advice and treatment from an appropriate medical provider. I understand that I am not creating a patient relationship with KDHE by participating in this testing. I understand the testing unit is not acting as my medical provider. 2. Patient Rights and Privacy Practices • I acknowledge and agree that KDHE may disclose my test results and associated information to appropriate county, state, or other governmental and regulatory entities as may be permitted by law. • I acknowledge and agree that some limited personal information including my name and contact information may be shared with public health authorities if I am identified as a close contact to a positive case. 3. Release • To the fullest extent permitted by law, I hereby release, discharge and hold harmless, KDHE, including, without limitation, any its respective officers, directors, employees, representatives and agents from any and all claims, liability, and damages, of whatever kind or nature, arising out of or in connection with any act or omission relating to my COVID-19 diagnostic test or the disclosure of my COVID-19 test results. By providing my electronic signature to KDHE, I acknowledge and agree that I have read, understand, and agreed to the statements contained within this form. I have been informed about the purpose of the COVID-19 diagnostic test, procedures to be performed, and potential risks and benefits. I have been provided an opportunity to ask questions before proceeding with a COVID-19 diagnostic test and I understand that if I do not wish to continue with the collection, testing, or analysis of a COVID-19 diagnostic test, I may decline to receive continued services. I have read the contents of this form in its entirety and voluntarily consent to undergo diagnostic testing for COVID-19. *

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