*Please fill out a different form for each individual getting a test. Patient Name(Required) First Name Middle Name Last Name Date of Birth(Required) Age(Required) Sex(Required)MaleFemaleRace(Required)Select...American Indian or Alaska NativeAsianBlack or African AmericanNative Hawaiian or Other Pacific IslanderWhiteOtherUnknownEthnicitySelect...HispanicNon-HispanicUnknownAddress(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Primary PhoneCell PhoneReferred BySelect...WebsiteGoogleSocial MediaWalk-InFriendFamilyReferral Patient or Parent/Guardian Photo ID Upload (Copy of Driver's License, State ID, or Passport)Front ID Image(Required) Drop files here or Select files Max. file size: 32 MB. Back ID Image(Required) Drop files here or Select files Max. file size: 32 MB. Consent for Direct Access Results I, First Name Last Name, hereby authorize NJ Covid to release results of tests associated with this request, that includes protected health information, directly to myself (or legal guardian, if indicated) via the Method of Results Release chosen below. This authorization will remain in effect until the request is fulfilled by NJ Covid and no longer. Myself or my physician may contact NJ Covid for all other requests for test results release not associated with this test requisition. I understand that my healthcare provider, and not NJ Covid, is responsible for consulting with me on all test results. I understand that signing this form is voluntary and that if I don’t sign, it will not affect the commencement, continuation or quality of services. If I change my mind, I understand that I can revoke this authorization by providing a written notice of revocation. The revocation will be effective immediately upon the laboratory's receipt of my written notice, except that the revocation will not have any effect on any action taken by the laboratory in reliance on this Authorization before it received my written notice of revocation.Email Address(Required) Signature(Required)If patient is a minor or is unable to sign this Authorization, Parent/Guardian please complete the information below:Patient/Guardian Patient/Guardian First Name Patient/Guardian Middle Name Patient/Guardian Last Name Legal Relationship Patient or Parent/Guardian Signature
