Professional Pharmacy Rapid Strep/Flu test

As of 8/1/2022 we are now located at 401 N Waco St, Wichita Ks 67202

Please come into the pharmacy upon arrival and check in with our staff.

You may text questions to 316-348-8517.

Please note that upon submission, we cannot issue refunds. Thank you!
Rapid Strep and/or Flu Testing

Flu Tes
Appointment Time*
Patient Full Legal Name*

First NameLast Name
Age*
Date of Birth

MonthDayYear
Date
Legal Guardian if under age 18

First NameLast Name
Guardian DOB

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

Street Address

Street Address Line 2

CityState

Zip Code
Cell Phone Number*
Email*
example@example.com
Biological Sex*

MaleFemale
Ethnicity (this information is used to report testing statistics)*

WhiteBlackAsianHispanic or LatinoNative Hawaiian or Other Pacific IslanderAmerican IndianMulti-RacialOther
Primary Care Provider (Doctor)*

First NameLast Name
Primary Care Provider (Doctor) Address*
Address/City/State
Check any of the following symptoms you are currently experiencing:*

CoughShortness of breath or difficulty breathingFatigueHeadacheFever or ChillsMuscle or Body AchesNew Loss of Taste or SmellNausea or VomitingDiarrheaCongestion or Runny NoseSore ThroatSymptoms above and a confirmed contact with a confirmed case of COVID-19.Symptoms above but a NEGATIVE Covid test has already been performed in the last 48 hours.
Please list the name of anyone who has helped you complete this form:
Comments/Concerns:
By signing below, you agree that your answers are true and accurate to the best of your ability, you will read the handout provided at the time of testing and you authorize Professional Pharmacy to release the results of your test to your primary provider. Your signature below indicates that you have been informed that we are unable to bill insurance for this test and you authorize the payment below. Additionally, you authorize the use of this electronic form and signature and understand there are no refunds available after this form is submitted and you consent to the receipt of our privacy policy at https://wichitapharmacy.com/privacy-policy *

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My Products

Rapid Strep (Group A) Test1 Rapid Diagnostic Strep A Test

$25.00

Rapid Flu A+B Test1 Rapid Influenza Diagnostic test

$45.00

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Subtotal

$0.00

Tax

$0.00

Total

$0.00

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Rapid Strep and/or Flu Testing

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