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COVID Home Test Positive Results Reporting

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.
3. Patient Sex
This question requires a valid date format of MM/DD/YYYY.
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5. Patient Primary Race
11. Patient Ethnicity
12. Test Name (Required) *This question is required.
This question requires a valid date format of MM/DD/YYYY.
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14. Is the patient under 18 years of age? (Required) *This question is required.
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