COVID-19 Rapid Antigen Test Order Form
Please note that these tests may have a short shelf life and may only be available for a short period of time, based on current supplies. Additional testing options may be available at a later date.
What are you ordering tests for?
What are you ordering tests for?
I am going to distribute these tests in my community.
County
In which county do you plan to distribute these tests?
Organization Details
Organization Name
Organization Type
Other Organization Type
Number of Staff/Administrators
Physical Address (No PO Boxes)
City
Zip
Contact First Name
Contact Last Name
Phone Number
Confirm Phone Number
Email Address
Confirm Email Address
Distribution Plan
Distribution Location Name
Distribution Location Address
Distribution Location City
Distribution Location Zip
In which zip codes will you distribute tests?
Which population disproportionately affected by COVID do you plan to reach? Check all that apply.
Has your organization previously distributed tests?
When did you distribute tests?
From
To
How many tests did you previously distribute?
At what kinds of locations will these tests be distributed? Check all that apply
How do you plan to distribute the tests?
What is your schedule for distribution?
Sunday -
Monday -
Tuesday -
Wednesday -
Thursday -
Friday -
Saturday -
How soon do you plan to distribute tests?
Would you be willing to review training videos on tests, educational
materials,
and isolation and quarantine?
Do you want your test distribution event to be added to the public testing directory? (www.findatestnm.org)
| Test Kit Option | Number Of Tests Per Box | Description | Number Of Boxes Requested |
|---|---|---|---|
| iHealth Rapid Antigen (small box) | 2 test/box | OTC and clinic use |
What are you ordering tests for?
I am going to use these tests in a clinic, shelter,
detention center, or similar setting.
County
In which county do you plan to distribute these tests?
Location Details
Location Name
What type of location are you?
Other Location Type
Number of Staff/Administrators
Number of Residents/Individuals Served
Physical Address (No PO Boxes)
City
Zip
Contact First Name
Contact Last Name
Phone Number
Confirm Phone Number
Email Address
Confirm Email Address
Do you have a CLIA waiver?
Tests
Please describe how the tests will be used (ex: guest screening, staff
testing,
outbreak management, etc)
| Test Kit Option | Number Of Tests Per Box | Description | Number Of Boxes Requested |
|---|---|---|---|
| eMED BinaxNOW Rapid Antigen* | 1 test/box | Telehealth-supported test | |
| iHealth Rapid Antigen (small box) | 2 test/box | OTC and clinic use | |
| iHealth Rapid Antigen (large box) | 40 test/box | OTC and clinic use |
*eMED tests are procotored online through the eMED system - access to a device with Wi-Fi or internet capability and a front-facing camera is required.
Note: NMDOH staff may modify, including increasing, decreasing, or denying, test requests based on prioritization, availability, and distribution options.