HOLIDAY COVID 19 Home Test Request Form

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

By completing this form, you are requesting COVID 19 Home Test Kits from the Union County Health Department to test in advance of the holiday season.
Test kits are available for pick up from 8:00 am to 4:00 pm Friday, December 15.

Pick up is at the County Services Building: 940 London Ave., Marysville, Oh. Please park your car and come to the door at the SW corner of the building marked "Union County Health Department STAFF ONLY" (look for signs and parking cones which are on the southwest front of the building).
At this time, we are allowing individuals to request the number of test kits needed for their family gathering. If demand exceeds our supply, we reserve the right to limit test kit availability per household.
One person may pick up for multiple households. Simply have name, last four digits of your phone number and the number of kits requested for additional household pick ups.
If you have any questions or problems, please call our office at 937-642-2053.
Thank you,
Union County Health Department

Email *

First name *

Last name *

Last 4 digits of your phone number *

Number of test kits needed *

Other:

Proctored tests like BINAX NOW will provide verified results through telehealth. Currently, UCHD no longer distributes proctored tests. *

Yes, I understand by checking this box I am reserving a non-proctored test.

For planning purposes, approximately when do you plan to pick up your test kits? *

8-9a Friday 12/15

9-10a Friday 12/15

10-11a Friday 12/15

11-12p Friday 12/15

12-1p Friday 12/15

1-2p Friday 12/15

2-3p Friday 12/15

3-4p Friday 12/15

Send me a copy of my responses.

Submit

Clear form

Never submit passwords through Google Forms.

reCAPTCHA

Privacy Terms

This form was created inside of Union County Health Department. Report Abuse

Forms