Register Your Kit You must register your kit before you can begin the collection process. Kit*Select a kitCOVID-19 Test KitPharmacogenetics Test KitPlease select the kit you are registering.Enter the code found on your sticker label* Sticker label MUST be fully filled out before sending your kit back to the lab.Please re-enter the code found on your sticker label* Sticker label MUST be fully filled out before sending your kit back to the lab.Birth Date* MM slash DD slash YYYY Collection Date* MM slash DD slash YYYY Collection Time* Hours : Minutes AM PM Please enter time in 12-hour format.Collection Time Zone*Select OneGMT -08:00 (US/Los Angeles)GMT -07:00 (US/Mountain)GMT -06:00 (US/Central)GMT -05:00 (US/Eastern)HiddenAge calc Are you registering this kit for a minor under the age of 18?*Select OneYesNo*Enter a birthdate above the age of 18Guardian First Name* Guardian Last Name* I have the following relationship with the minor taking this test*Select OneFatherMotherGrandfatherGrandmotherStepfatherStepmotherAdult AuntAdult UncleAdult BrotherAdult SisterCourt ordered legal guardianAge*Patient First Name* Patient Last Name* Address* Street Address Address Line 2 City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Phone* +1 () Email* Enter Email Confirm Email Department of Health & Human Services QuestionsPlease enter the information below for the person who will be taking the test. Please ensure your answers are accurate as they can affect the results of the test.Is this your first COVID-19 test (PCR or antibody)?*Select OneYesNoUnknownAre you employed in a healthcare setting?*Select OneYesNoUnknownDo you have COVID-19 symptoms (fever, cough, shortness of breath, etc.)?*Select OneYesNoUnknownWhat was the date that your symptoms started? MM slash DD slash YYYY Are you currently in the hospital?*Select OneYesNoUnknownAre you currently in the ICU?*Select OneYesNoUnknownDo you live or work in a congregate setting (including nursing homes, residential care for people with intellectual and developmental disabilities, psychiatric treatment facilities, group homes, board and care homes, homeless shelter, foster care or other setting)?*Select OneYesNoUnknownAre you pregnant?*Select OneYesNoUnknownAdditional QuestionsSex assigned at birth*Select OneMaleFemaleOtherEthnicity*Select OneHispanic or LatinoNot Hispanic or LatinoOtherPrefer not to answerRace* American Indian and Alaska Native Asian Black or African American Native Hawaiian and other Pacific Islander Two or more races White Other Prefer not to answer Select all that applyHave you been diagnosed with or experienced any of the below?* Presence of hematologic malignancy History of recent blood transfusion History of bone marrow/stem cell transplant Current liver or kidney failure History of liver transplant None of the above Select all that applyWhat is your primary reason for ordering this test?*Select OneI’m Interested in knowing how my genes might affect my medicationsI have a history of adverse drug reactions or ineffective medicationsI’m going on a medication and wondering if it is right for me based on my geneticsMy provider recommended itCurrent Medications (generic)*No medicationsAmitriptylineAmoxapineAmphetamineAripiprazoleCarisoprodolCarvedilolCelecoxibCevimelineCitalopramClomipramineClopidogrelClozapineCodeineDesipramineDiazepamDonepezilDoxepinDronabinolEfavirenzEscitalopramEsomeprazoleFesoterodineFlurbiprofenFluvoxamineFosphenytoinGalantamineGefitinibHydrocodoneIbuprofenIloperidoneImipramineLansoprazoleMeclizineMeloxicamMethadoneMetoclopramideMetoprololMirabegronNebivololNortriptylineOmeprazoleOndansetronPantoprazoleParoxetinePerphenazinePhenytoinPimozidePiroxicamPropafenonePropranololProtriptylineRabeprazoleRisperidoneSertralineSimvastatinTacrolimusTamoxifenTamsulosinTetrabenazineThioridazineTolterodineTramadolTrimipramineVenlafaxineVoriconazoleWarfarinPlease select all medications you are currently taking. Are you currently being treated by a doctor for a kidney or liver problem?*Select OneYesNoWhich kidney or liver problems are you seeing a doctor for?* kidney stones kidney dialysis liver cirrhosis kidney infection in the last 6 weeks kidney failure in the last 6 weeks eclampsia/pre-eclampsia (Pregnancy-related hypertension) lupus nephritis HIV infection polycystic kidneys other I don't know Select all that applyReview for impact on drug metabolism* Customer Consent*Individual acknowledgment: If this test was ordered for personal use, your results will only be shared with customer listed on the registration form. Employee acknowledgment: If this kit was ordered through an employer, I understand my results will be shared with your employer for internal COVID-19 tracking. Results will only be shared with the employer and customer. Agree Minor User Consent*I ,FIRST LAST, have the legal authority, based on the relationship to the child as indicated above to consent to this test administration for the child named. I authorize any physician or health care provider or authorized provider examining or testing my minor child to use or disclose protected health information for reporting purposes. Agree HiddenGuardian EUA agreed date Guardian EUA agreed date*Certain conditions and treatments may impact the interpretation of your results. As you have been diagnosed with one or more contraindications for genetic or pharmacogenetic testing you can not submit the registration.