Lake County Health Department/Community Health Center
BinaxNOW Request Form
Contact Information:
Facility Name
Facility Address:
Name of Requestor:
Direct Phone Number:
Quantity of BinaxNOW Tests Requested:
Does the program meet all the requirements needed to provide BinaxNOW
testing as outlined in our Pr
otocol for Dissemination of BinaxNOW Tests During
COVID-19?
Yes No
-------------TO BE COMPLETED BY LAKE COUNTY HEALTH DEPARMENT/COMMUNITY HEALTH CENTER---------------
Signature of LCHD Liaison (if applicable):
Type of Facility
(e.g., Long Term Care, PD/FD, Home Health, Hospital,
School, Daycare, etc.)
Number of BinaxNOW Tests Picked Up:
Date of Pick Up:
Signature of Staff Picking Up:
Completed order forms should be submitted to Paul Thomas at Lake County Health Department via email at
pthomas@lakecountyil.gov and (cc Noor AlHayani, nalhayani@lakecountyil.gov).
