COVID-19 Patient Test Enrollment Form Each Patient must complete a separate form. Incomplete forms may result in delayed test results. Tests must be performed by a licensed practitioner. Vibrant America COVID19 Patient Registration Form First Name * Last Name * Address * Address Address Address City City State Alabama Alaska Arkansas Arizona California Colorado Connecticut Delaware District of Columbia Florida Georgia 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 Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming State Zip Zip Email * Phone Identification Type * Drivers License State Issued ID Card Passport Military ID Patient Identity Confirmed by Practitioner Identification Number Issuing State or Foreign State/Province & Country Birthday * Practitioner Name * Practitioner Email (if known) I hereby give you permission to convey my test results via: * Email Text Message Voice Message Telephone Regular Mail Signature Clear reCAPTCHA Test Registration Number (Internal Use Only) Status Test Ordered Test Cross Checked VA Test Results Complete Test Results Conveyed Test Results Will Appear Here (Internal Use Only) Choose File Maximum upload size: 16.78MB If you are human, leave this field blank. Submit