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COVID-19 Testing Consent under Emergency Use Authorization
Step 1: Account Set up
اطلاعات بیمار
Check the box if you don't have an email.
Email
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* must only contain alphanumeric and _!~@#$%^&*-
* Please enter a valid password that matches
Check the box if you don't have phone number
Cell Phone
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Step 2: Patient Registration
زمینه اجباری:
نام بیمار
Patient Middle Name
نام خانوادگی بیمار
تاریخ تولد
Month
ژانویه
فوریه
مارس
آوریل
مه
ژوئن
ژوئیه
اوت
سپتامبر
اکتبر
نوامبر
دسامبر
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
1874
1875
1876
1877
1878
1879
1880
1881
1882
1883
1884
1885
1886
1887
1888
1889
1890
1891
1892
1893
1894
1895
1896
1897
1898
1899
1900
1901
1902
1903
1904
1905
1906
1907
1908
1909
1910
1911
1912
1913
1914
1915
1916
1917
1918
1919
1920
1921
1922
1923
1924
1925
1926
1927
1928
1929
1930
1931
1932
1933
1934
1935
1936
1937
1938
1939
1940
1941
1942
1943
1944
1945
1946
1947
1948
1949
1950
1951
1952
1953
1954
1955
1956
1957
1958
1959
1960
1961
1962
1963
1964
1965
1966
1967
1968
1969
1970
1971
1972
1973
1974
1975
1976
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
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
جنسیت
جنسیت را انتخاب نمائید
Male
Female
Transgender
Undefined
Please check the box if you are an International Patient
آدرس خیابان
شهر
کد پستی
State
استان را انتخاب نمائید
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
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