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Section I. Personal Information
Section IV. Signature
By signing this form, I give consent for Graves Drug to send my testing results to the Kansas State Department of Health and Welfare and verify that I am not being tested for travel or any other reasons stated above to be not included in the state of Kansas community testing partner funding.
By clicking the "Submit" button below, you certify that the above information is correct and accurate to the best of your knowledge. All information is confidential and is accessed only via a secure, encrypted interface.