COVID-19 Testing Appointment Form

Testing Appointment Form

Initial Survey
Testing will be done by appointment ONLY.

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 24 hours.

Covid tests - $10

Influenza A & B - $10

RSV - $10

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

If you are requesting a test for a procedure or travel, the cost is $25.00.

Call once you arrive: 816-586-2311 and we will meet you at the door. Please wear a mask.
What test are you requesting?*

COVID-19 - $10Flu A&B - $10RSV - $10
Why are you requesting a test?*

SymptomaticMedical procedure/Travel
Are you currently experiencing any symptoms?*

Fever/ChillsFatigueCoughHeadacheDifficulty breathingLoss of taste and/or smellBody achesNasal congestionRunny noseSore throatGI symptomsNoneOther
Date symptoms began*

MonthDayYear
Schedule Appointment*
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Gender*

MaleFemale
Ethnicity*

HispanicNon-Hispanic
Race*

American IndianAsianBlackPacific IslanderWhiteOther
Email
Address*

Street Address

County

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
Call once you arrive: 816-586-2311 and we will meet you at the door. Please wear a mask.
Should be Empty: