COVID-19 Resource Request Form

This resource request portal is for the purpose of providing free At-Home COVID-19 tests to Shawnee County residents.

Resource requests will be evaluated, and items provided at the discretion of the Shawnee County Health Department as supplies allow.

It is not allowable to profit from or sell any resources allocated by the Shawnee County Health Department.

Pickup is available 2 business days after request is made at our 2115 SW 10th Ave. location Monday - Friday during clinic hours:

Monday, Thursday, Friday - 8am-11am, 1pm-4pm
Tuesday - 10am-1pm, 3pm-6pm
Wednesday - 8am-11am, 2pm-4pm

1. Please select one of the following: *This question is required.

Individual - limit of 5 tests per household
Social Service/Non-Profit

2. Please provide the name of the organization *This question is required.

2. How many At-Home COVID-19 tests would you like to request? *This question is required.

3. First Name *This question is required.

4. Last Name *This question is required.

5. Address including city and state and zip code *This question is required.

6. Phone Number *This question is required.

7. Email Address *This question is required.

8. Special requests: