HESSTON Covid Rapid Antigen Test

Need a FREE COVID-19 test?

Please fill out the information below to schedule your COVID-19 Rapid Antigen test at HESSTON PHARMACY 101 S. MAIN, HESSTON.
Name

First NameLast Name
Name of Parent or Guardian if patient less than 18 years of age

First NameLast Name
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Kansas County of Residence

Other
Patient Date of Birth

MonthDayYear
Parent or Guardian Date of Birth if patient is less than 18 years (or Confirm Patient Patient Date of Birth if over 18)

MonthDayYear
Date
E-mail
example@example.com
Preferred Contact Number:
Format: (000) 000-0000.
Biological Sex
Race
Is this the first Covid-19 test (of any kind) for this patient?
Is the patient employed in a healthcare setting?
Is the patient symptomatic (per CDC)
Has the patient been hospitalized for Covid-19?
Has the patient been in the ICU for Covid-19?
Do you live in a group living setting?
Are you pregnant?
By selecting "yes" below, I agree to give verbal informed consent to the testing prior to receiving the test. I understand that I will not be allowed to test if I do not provide verbal consent to testing prior to the test. A copy of the Consent Form is included with the Thank You page after completing your appointment
What is your status in regards to Covid-19 vaccine?
I authorize the pharmacy to send the results of my test to my Primary Care Provider: (please include Provider name and Phone #)
One Last Step! It's time to make your APPOINTMENT! (be sure to hit "enroll" when you are done)
What's Next?

On the day/at the time of your appointment, please come to Hesston Pharmacy (101 South Main Street) and PULL AROUND BEHIND THE STORE TO OUR DRIVE-UP AREA. Remain in your vehicle, with the windows up. Please call (620)327-2211 and a member of our team will be out to help you shortly. Thanks so much!
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Need a FREE COVID-19 test?

What's Next?