MP3: Lab Testing Screening Form

MP3: Lab Testing Registration Form
Please complete this confidential registration form to the best of your ability. After you have completed this form you may schedule your test date, time, and location.

The results of your test are confidential and protected by law. However, health care practitioners (health care facilities and medical laboratories) are required to report disease to the Minnesota Department of Health (MDH) under Minnesota state law [45 CFR § 164.512(a)]. What conditions are reportable?
Part 1: Patient Demographic Information
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
What sex were you assigned at birth?*

MaleFemale
Cell Phone Number*
Please enter a valid mobile phone number - this is how you will receive your result. We will never disclose test results in a voicemail. A secure portal account will be created for you at this phone number and is where you will securely obtain your test results.
Email*
Please enter a valid email address that you have access to.
Home Address*

Street Address

Street Address Line 2

CityState

Zip Code
Race/Ethnicity*
Desired Testing Location (please pick one only)*

BurnsvilleMinneapolisWoodburyRochester

	Yes	No	I Don't Know
Gonorrhea
Chlamydia

	Yes	No	I Don't Know
Gonorrhea
Chlamydia

MP3: Lab Testing Registration Form