At-Home Test Form
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All rights reserved
Which test are you taking?*
Select a Test
Which COVID-19 Test?
Org, Employer, school or entity test is for?:*
Employee ID (optional):
Unique ID (optional):
Date of Birth:*
Phone Number (optional):
Address Line 2 (Optional):
Please select a Gender
Please enter your gender...
Begin your test...
What was your Test Result?*
Upload Image of Your Test Result:
allowed image types: png, jpg, jpeg, gif
| max image upload size:
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
Tip: Use your mouse if on Desktop or your finger if on a mobile device or tablet.
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
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.
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