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Antibody Intake Form
Antibody Intake Form
Legal Name
*
First
Last
Referred By
Employer Name
Date
*
Date Format: MM slash DD slash YYYY
Date of Birth
*
Date Format: MM slash DD slash YYYY
Sex
Male
Female
Height
Feet
Inches
Weight
Address
*
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
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Belarus
Belgium
Belize
Benin
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Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
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Bouvet Island
Brazil
British Indian Ocean Territory
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Burundi
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Cameroon
Canada
Cape Verde
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Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
CuraƧao
Cyprus
Czech Republic
CƓte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
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El Salvador
Equatorial Guinea
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Ethiopia
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French Polynesia
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Georgia
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Hungary
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Indonesia
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Iraq
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Isle of Man
Israel
Italy
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Japan
Jersey
Jordan
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Libya
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Mali
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Mayotte
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Montserrat
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Myanmar
Namibia
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Netherlands
New Caledonia
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Nicaragua
Niger
Nigeria
Niue
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North Korea
Northern Mariana Islands
Norway
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Palestine, State of
Panama
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Paraguay
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Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
RƩunion
Saint BarthƩlemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
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Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia
South Korea
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Spain
Sri Lanka
Sudan
Suriname
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Sweden
Switzerland
Syria
Taiwan
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Thailand
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Tonga
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Uganda
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United States
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Uzbekistan
Vanuatu
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
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Zimbabwe
Ć land Islands
Country
Email
*
Phone
*
Allergies
*
Latex
Alcohol
Other
None
If Other Allergies selected ( Please list)
If Other Allergies selected ( Please list)
Emergency Contact Phone Number
Has the patient had contact with a confirmed or suspected COVID-19 case within last 14 days?
*
Yes
No
Within the last 14 days, have you been experiencing any of the following
*
Fever
Chills
Cough
Shortness of Breath
None
Other
If Other, please specify
Has the patient had contact with anyone with an unexplained respiratory illness within last 14 days?
*
Yes
No
Relevant Past Medical History/Risk Factors
Asthma/Pulmonary Condition
*
Yes
No
Hypertension/Cardiac Disease
*
Yes
No
Hyperlipidemia
*
Yes
No
Digestive
*
Yes
No
Diabetes
*
Yes
No
Auto Immune Conditions
*
Yes
No
Osteoarthritis
*
Yes
No
Muscle Pain or Cramps
*
Yes
No
Joint Pain Stiffness/Swelling
*
Yes
No
Back/Neck Pain
*
Yes
No
Anxiety
*
Yes
No
Insomnia
*
Yes
No
Depression
*
Yes
No
COVID-19 ANTIBODY CONSENT
*
I understand that this test looks for antibodies to COVID-19, NOT the virus itself. Testing for viral DNA, via PCR analysis, is performed only in specifically designated places and on patients who meet a strict pre-test criteria. I am electing to have this antibody test to assess whether or not I have been exposed to the novel coronavirus in the past. I additionally understand that if I choose to have this test fewer than seven days after the resolution of symptoms, the results may be less reliable. I hereby attest that I have been advised to take this test only as a completely asymptomatic individual. I have never had symptoms or at least have been symptom-free for seven days. I also understand that the results of this test may be given to the department of health or CDC for their statistical and demographic value. Once I am given my results for this test, I understand that they are only a preliminary measure of IgG/IgM antibodies (qualitative measure) and that the values of antibodies (quantitative measures) may vary. This test does not guarantee immunity to COVID-19 or any other virus.
Patient's Name
*
Patient's Signature
*
Date
Date Format: MM slash DD slash YYYY
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Locations
New York City
70 East 55th Street, 2nd Floor
New York, NY 10022
212.486.8616
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New Windsor
17 Oakwood Terrace New Windsor,
NY 12553
845.836.1101
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