COVID-19 Rapid Antigen Testing
Appointment and Registration Form
Test results are usually available in 1-2 hours
PATIENTXCHANGE will contact you directly with test results
Thank you for choosing Kollhoff Pharmacy!
Please enter information below to schedule an appointment
Appointment
*
Name
*
First Name
Last Name
Birth Day
*
-
Month
-
Day
Year
Guardian Name
*
First Name
Last Name
Guardian Birth Day
*
-
Month
-
Day
Year
Cell Phone Number
*
-
Area Code
Phone Number
Email
*
example@example.com
I would like my results reported to me via:
*
text
email
Back
Next
After choosing "submit," you will be directed to PATIENTXCHANGE to register for your rapid COVID-19 test.
Submit
Should be Empty: