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COVID-19 Home Test Reporting Form
Please use this form to report a POSITIVE non-proctored home COVID-19 test only.
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* Indicates required question
Patient's Information
Patient's Last Name
*
Your answer
Patient's First Name
*
Your answer
Patient's Date of Birth
*
MM
/
DD
/
YYYY
Sex
*
Male
Female
Prefer not to say
Patient's Full Address
*
Street Address, City, State, Zip (***Please make sure to include City, State and Zip!***)
Your answer
Patient's Phone Number
*
XXXXXXXXXX
Your answer
Race
American Indian or Alaskan Native
Asian
Black
Native Hawaiian or Pacific Islander
White
Unknown
Other:
Ethnicity
Choose
Hispanic
Non-Hispanic
Unknown
Did patient have direct contact with a known COVID-19 Case?
Yes
No
Unknown
Clear selection
Test Name
*
Home Antigen Test
Other:
Required
Date Tested
*
MM
/
DD
/
YYYY
Test Result
*
Positive
Required
Signature/Guardian Signature - I hereby certify that the information is true and accurate and I confirm that I want to submit this lab result on behalf of myself or the minor identified on this form. (Please enter full name for Signature)
Your answer
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