Harvey Drug Covid Rapid Antigen Test

Need a FREE COVID-19 test? Sign up below for a RAPID ANTIGEN COVID-19 Test. Results will be emailed to patient 15-30 minutes after testing.
Patient Name*

First NameLast Name
Patient Date of Birth*

MonthDayYear
Name of Parent or Guardian if patient less than 18 years of age. NOTE: This information MUST be provided or children under 18 years will not be allowed to test. Children must be accompanied by an adult.

First NameLast Name
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent or Guardian Date of Birth if patient is less than 18 years (or Confirm Patient Date of Birth if over 18) NOTE: This information MUST be provided or children under 18 years will not be allowed to test. Children must be accompanied by an adult.

MonthDayYear
Date
E-mail*
example@example.com
Kansas County of Residence*

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

Yes – 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 results of the test to my Primary Care Provider: (please include provider name and phone number)
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
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 (select below), please come to Harvey Drug (115 West 5th Street, Newton) and DRIVE UP TO OUR DRIVE-THRU WINDOW. Remain in your vehicle, with the windows up. Please call (316)333-0120 and a member of our team will be over to help you shortly. Thanks so much!
After selecting "enroll" you will receive a CONFIRMATION EMAIL. If you do not receive the email, PLEASE DO NOT CALL THE PHARMACY. WE CANNOT ENROLL PATIENTS OR CONFIRM APPOINTMENTS OVER THE PHONE. Please simply try to sign up again and make sure you do not skip any of the questions. Type Yes below to confirm you have read this information...Thanks so much!!!
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Need a FREE COVID-19 test? Sign up below for a RAPID ANTIGEN COVID-19 Test. Results will be emailed to patient 15-30 minutes after testing.

What's Next?