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BinaxNow Rapid Antigen Card

  1. Homeless*

  2. Result*

  3. Any Symptoms?*

    (eg, runny nose, cough, fever, loss of taste and smell, fatigue, headache, chills, difficulty breathing, etc)?

  4. Any close contact exposure to a COVID-19 case in the last 14 days?*

  5. Employer*

  6. Leave This Blank:

  7. This field is not part of the form submission.