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COVID-19 Self Test
If you are vaccine exempt and did not submit a proof of recovery and proof of a positive viral test within the last 90 days, you must submit your antigen test result daily.
Which test are you taking?*
Select a Test
Abbott BinaxNOW
Lucira
QuickVue
Carestart
Inteliswab
Other
Which COVID-19 Test?
Org, Employer, school or entity test is for?:*
Employee ID (optional):
Unique ID (optional):
First Name:*
Last Name:*
Date of Birth:*
Email Address:*
Phone Number (optional):
Home Address:
Address Line 2 (Optional):
City:
State Abbrev:
Zip/Postal Code:
Gender:
Please select a Gender
Male
Female
Other
Please enter your gender...
Begin your test...
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What was your Test Result?*
Negative
Positive
Upload Image of Your Test Result:
allowed image types: png, jpg, jpeg, gif
| max image upload size:
8Mb
Additional Comments?
Test Submission Consent:
Please select one
Self - 18 or older
UNDER 18 - Parent or Guardian Consent
Please enter your full name if you’re the parent/legal guardian
Your Signature:
Tip: Use your mouse if on Desktop or your finger if on a mobile device or tablet.
Clear Signature
Your Signature Typed:*
By checking this box and submitting your test result, you are attesting and confirming that you are 18 years of age or older and that this test was self administered on the date of submission.
I give consent and agree to the
Waiver
*
Submit Test Result
Note: If you’re uploading a big PDF or image, please wait for the form to finishing uploading it to our secure system, then you’ll see a confirmation page.
HIPAA COMPLIANCE DISCLAIMER & PRIVACY NOTICE