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COVID-19 Testing Consent under Emergency Use Authorization
Step 1: Account Set up
রোগীর তথ্য
Check the box if you don't have an email.
Email
Email and phone can't be all blank!
show password
hide password
* must only contain alphanumeric and _!~@#$%^&*-
* Please enter a valid password that matches
Check the box if you don't have phone number
Cell Phone
Email and phone can't be all blank!
Step 2: Patient Registration
ম্যান্ডেটরি ফিল্ড:
Patient First Name
Patient Middle Name
Patient Last Name
জন্ম তারিখ
Month
জানুয়ারি
ফেব্রুয়ারি
মার্চ
এপ্রিল
মে
জুন
জুলাই
অগাস্ট
সেপ্টেমবার
অক্টোবার
নভেম্বার
ডিসেম্বার
Day
1
2
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31
Year
1874
1875
1876
1877
1878
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1880
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1882
1883
1884
1885
1886
1887
1888
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1911
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1982
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1989
1990
1991
1992
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1995
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1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
2021
2022
2023
2024
লিঙ্গ
লিংগ নির্বাচন
Male
Female
Transgender
Undefined
Please check the box if you are an International Patient
রাস্তার ঠিকানা
শহর
জিপ কোড
State
রাজ্য নির্বাচন কর
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
the Northern Mariana Islands
the U.S. Virgin Islands
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
County Name
-- Select County --
ALACHUA
BAKER
BAY
BRADFORD
BREVARD
BROWARD
CALHOUN
CHARLOTTE
CITRUS
CLAY
COLLIER
COLUMBIA
DADE
DESOTO
DIXIE
DUVAL
ESCAMBIA
FLAGLER
FRANKLIN
GADSDEN
GILCHRIST
GLADES
GULF
HAMILTON
HARDEE
HENDRY
HERNANDO
HIGHLANDS
HILLSBOROUGH
HOLMES
INDIAN RIVER
JACKSON
JEFFERSON
LAFAYETTE
LAKE
LEE
LEON
LEVY
LIBERTY
MADISON
MANATEE
MARION
MARTIN
MONROE
NASSAU
OKALOOSA
OKEECHOBEE
ORANGE
OSCEOLA
PALM BEACH
PASCO
PINELLAS
POLK
PUTNAM
SANTA ROSA
SARASOTA
SEMINOLE
ST. JOHNS
ST. LUCIE
SUMTER
SUWANNEE
TAYLOR
UNION
UNKNOWN
VOLUSIA
WAKULLA
WALTON
WASHINGTON
OUT-OF-STATE
Race
Select Race
AMERICAN INDIAN/ALASKAN
ASIAN INDIAN
BLACK/AFRICAN AMERICAN
CHINESE
FILIPINO
GUAMANIAN/CHARMORRO
HAWAIIAN
JAPANESE
KOREAN
OTHER ASIAN
OTHER NONWHITE
OTHER PACIFIC ISLANDER
SAMOAN
UNKNOWN
VIETNAMESE
WHITE
Ethnicity
Select Ethnicity
Hispanic or Haitian origin
NOT Hispanic or Haitian origin
Unknown
Passport Number
Where did you hear about Pharmco?
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Google Search
Social Media
Friend
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* hCaptcha is mandatory.
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