Language
English (US)
COVID Test Result Submission
Use this form to share pictures of your COVID test results (if you get your results via email you can forward to info@clinicwithaheart.org).
Submission Date?
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Month
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Day
Year
Date
Patient Name
*
First Name
Last Name
Date of Birth
*
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Month
-
Day
Year
Date
Photo of your test results.
Photo #2 if needed.
Submit
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