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*

HarveySedgwickMarionMcPhersonRenoOther
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:*
Biological Sex*
Race*
Is this the first Covid-19 test (of any kind) for this patient?

YesNoUnknown
Is the patient employed in a healthcare setting?

YesNoUnknown
Is the patient symptomatic (per CDC)

YesNoUnsure
Has the patient been hospitalized for Covid-19?

YesNoUnsure
Has the patient been in the ICU for Covid-19?

YesNoUnsure
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*

Yes
What is your status in regards to Covid-19 vaccine?

I am fully vaccinated (all doses and at least 2 weeks complete since last dose)I am NOT fully vaccinated
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?