Otogenetics COVID-19 Antibody Test Result
This form does not contain or require the submission of any protected health information.
Testing Facility *
Test Barcode # OR Patient ID *
Test Date *
MM
/
DD
/
YYYY
Specimen Collection Date
If different from Test Date
MM
/
DD
/
YYYY
Specimen Type(s)
Result *
Required
Reason for Testing *
Multiple Choice
Required
Symptoms Onset Date
MM
/
DD
/
YYYY
Suspected Infection Date
MM
/
DD
/
YYYY
Symptoms
Multiple Choice
High Risk Occupation
Clear selection
Overseas Travel Location (Country, Region)
Other COVID-19 Tests Performed
Other COVID-19 Test Results
Clear selection
Patient Sex
Clear selection
Patient Age
Patient Ethnicity
Patient Zip Code
Additional Comments
Submit
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