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Rapid Covid 19 Test Registration -Form Fill
Q1
First Name
Name*
Q2
Last Name
Name*
Q3
Date of Birth
Q4
Phone Number*
Q5
Email*
Q6
Street Address
Address*
Q7
Address*
Address*
Q8
City
Address*
Q9
State / Province
Address*
Q10
Postal / Zip Code
Address*
Q11
Are you or could you be pregnant?
Yes
No
Q12
Gender (optional)
Male
Female
Q13
Race (optional)
Please Select
Asian or Pacific Islander
Black
Multiracial
Native American or Alaskan Native
White
Other
Prefer not to say
Q14
Please select the site
West Seneca
Lockport
Q15
Signature
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