Covid-19 + Flu A&B Test Kit Request Form

Covid-19 + Flu A&B Test Kit Request Form
Your requested Covid-19+FluA&B Test Kit will be ready for pick up during standard operating hours at the front desk of Jackson County Public Health.

Our address is 3651 NE Ralph Powell Rd, Lee's Summit MO, 64064, and we are open Monday-Friday from 8 am to 4 pm.

One kit includes:
- 2 at-home tests for COVID-19 and Flu A&B
- 2 KN95 masks
- 1 hand sanitizer
- 1 paper bag to store your masks
- 1 informational insert with the current CDC guidelines
If you are requesting testing supplies on behalf of an organization, or are seeking more than 2 kits, please reach out directly to Estela Fernandez, our Clinical Outreach Coordinator, at (816) 404-6406 or estela.fernandez@uhkc.org.

Out of area? If you are outside the KC metro area, you can find no-cost Covid-19 testing resources near you here.
Today's date*

MonthDayYear
Order number*
Name*
Your name will only be used to coordinate your pick up. You may use a nickname, initials, or your order number (above).
What is your zip code?*
Type "NA" if you do not wish to answer.
What is your age?*

Under 18 years old18 - 24 years old25 - 34 years old35 - 44 years old45 - 54 years old55 - 64 years old65 - 74 years old75 years old or olderPrefer not to answer
What is your race?*

American Indian or Alaska NativeAsianBlack or African AmericanNative HawaiianTwo or more racesWhiteI only identify as Hispanic/LatinoPrefer not to answerOther
Do you identify as Hispanic or Latino/a/e?*

Yes, Hispanic or Latino/a/eNo, not Hispanic or Latino/a/ePrefer not to answer
How many kits would you like?*
One kit contains two (2) at-home tests.
Email
Email will only be used to send an order confirmation receipt and a satisfaction survey.
How did you hear about this program?*

JCPH staffSocial mediaNews coverageResource listCommunity organizationOther
By checking this box, I hereby attest that all information provided in this form is true and accurate to the best of my knowledge.*

I agree.
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