Please complete the following form to report a POSITIVE at-home test result for yourself or someone in your household. Your responses will remain confidential.

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* 1. Patient Last Name

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* 2. Patient First Name

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* 3. Patient Sex

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* 4. Patient Date of Birth (MM/DD/YY)

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* 5. Patient Primary Race

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* 6. Patient Address Street 1

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* 7. Patient Address Street 2

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* 8. Patient Address City

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* 9. Patient Address Zip

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* 10. Patient Phone Number (numbers only, no dashes)

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* 11. Patient Ethnicity

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* 12. Test Name

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* 13. Date Test was taken (MM/DD/YY)

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* 14. Is the patient under 18?

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* 15. Guardian Last Name

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* 16. Guardian First Name

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* 17. Guardian Phone Number (no dashes)

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