COVID-19 Testing Appointment Form

1

Testing will be done by appointment ONLY from 9 am-Noon.

Test results will be called to you when they are received by staff, please wait for their call.

Return times vary most results will be back in 48 hours.

WE WILL NOT DO RETESTS OR TESTS TO GO BACK TO WORK/SCHOOL!

If you are requesting a test for a procedure, the cost is $50.00.

If you are requesting a test for travel, the cost is $75.00.

Attention: Please enter through the NORTH/SIDE door that is marked COVID TESTING.

Call once you arrive: 816-586-2311 and we will meet you at the door. Please wear a mask.

2

Have you been tested here before?* This field is required.

YESNO

3

When was your last test?* This field is required.

4

Why are you requesting a test?* This field is required.We will not to retests or tests to return to school/work!!

Symptomatic

Medical procedure

Travel

6

Date symptoms began* This field is required.

Date

7

Schedule Appointment* This field is required.

8

Name* This field is required.

First Name

Last Name

9

Date of Birth* This field is required.

Date

10

Gender* This field is required.

Male

Female

11

Ethnicity* This field is required.

Hispanic

Non-Hispanic

13

EmailResults will be emailed to this address.

14

Address* This field is required.

Street Address

County

City

State / Province

Postal / Zip Code

Country

15

Phone Number* This field is required.

Area Code

Phone Number

16

Insurance* This field is required.

Insurance Provider

Insured Name and DOB

ID Number

Group Number