Patient Information

• Ethnicity*
  • Hispanic or Latino
  • Non-Hispanic or Non-Latino
  • Unknown
• Race*
  • White
  • Black or African American
  • Asian
  • Native Hawaiian or Other Pacific Islander
  • American Indian or Alaskan Native
  • Other
• Pregnancy Status*
  • Pregnant
  • Not Pregnant
  • Unknown
  • Not Applicable
• Hosp. Status
  • Inpatient
  • Outpatient
  • Emergency Dept.
  • Unknown
• ICU
  • Yes
  • No
  • Unknown
• History of recent international travel?*
  • Yes
  • No
  • Unknown

Primary Care Provider

If applicable please fill out the fields below; If not applicable please indicate "N/A" in the Physician Name Field.

Submitting Facility / Laboratory Information

Specimen Information

Test Performed