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ANDOR LABS DRIVE-UP
Patient Information
Patient Name
Date of Birth
Month
January
February
March
April
May
June
July
August
September
October
November
December
Gender
[Gender]
Male
Female
Phone
Email
Driver License
[State]
AA
AE
AK
AL
AP
AR
AS
AZ
CA
CO
CT
DC
DE
FL
FM
GA
GU
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MH
MI
MN
MO
MP
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
PR
PW
RI
SC
SD
TN
TX
UT
VA
VI
VT
WA
WI
WV
WY
SSN
Address1
Address2
State
AA (Armed Forces Americas)
AE (Armed Forces Europe)
Alaska
Alabama
AP (Armed Forces Pacific)
Arkansas
American Samoa
Arizona
California
Colorado
Connecticut
District of Columbia
Delaware
Florida
Federated States of Micronesia
Georgia
Guam
Hawaii
Iowa
Idaho
Illinois
Indiana
Kansas
Kentucky
Louisiana
Massachusetts
Maryland
Maine
Marshall Islands
Michigan
Minnesota
Missouri
Northern Mariana Islands
Mississippi
Montana
North Carolina
North Dakota
Nebraska
New Hampshire
New Jersey
New Mexico
Nevada
New York
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Palau
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Virginia
Virgin Islands
Vermont
Washington
Wisconsin
West Virginia
Wyoming
City
Zip
County
First test?
[Select]
Yes
No
U
Employed in healthcare?
[Select]
Yes
No
U
ICU?
[Select]
Yes
No
U
Hospitalized?
[Select]
Yes
No
U
Symptomatic as defined by CDC?
[Select]
Yes
No
U
if yes, then Date of Symptom Onset
Month
January
February
March
April
May
June
July
August
September
October
November
December
Pregnant?
[Select]
Yes
No
U
Travel Based Required Test?
[Select]
Yes
No
U
Lab To Lab Referral?
[Select]
Yes
No
U
Resident in a congregate care setting (including nursing homes, residential care for people with intellectual and developmental disabilities, psychiatric treatment facilities, group homes, board and care homes, homeless shelter, foster care or other setting):
[Select]
Yes
No
U
Insurance Information
Insurance
[Select Insurance]
Uninsured - Self Pay
I have insurance
Policy
Group
Relationship
[Relationship to Insured]
Self
Spouse
Child
Other
Insured Name
Date of Birth
Month
January
February
March
April
May
June
July
August
September
October
November
December
Gender
[Insured Gender]
Male
Female
Address
[Insured Address]
Same as patient address
Different address
Address1
Address2
State
AA (Armed Forces Americas)
AE (Armed Forces Europe)
Alaska
Alabama
AP (Armed Forces Pacific)
Arkansas
American Samoa
Arizona
California
Colorado
Connecticut
District of Columbia
Delaware
Florida
Federated States of Micronesia
Georgia
Guam
Hawaii
Iowa
Idaho
Illinois
Indiana
Kansas
Kentucky
Louisiana
Massachusetts
Maryland
Maine
Marshall Islands
Michigan
Minnesota
Missouri
Northern Mariana Islands
Mississippi
Montana
North Carolina
North Dakota
Nebraska
New Hampshire
New Jersey
New Mexico
Nevada
New York
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Palau
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Virginia
Virgin Islands
Vermont
Washington
Wisconsin
West Virginia
Wyoming
City
Zip
County
Upload Documents
Driver License
-
FileName
Insurance Card - Front
-
FileName
Insurance Card - Back
-
FileName
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