*First Name (required)

*Last Name (required)

*Your Phone (required)

*Your Email (required)

*Your Date of Birth (required)

*Biological Sex (required)
MaleFemale

*Ancestry (required)
CaucasianAfrican AmericanAsianHispanicOther

*Medical Conditions (required)
DiabetesHeart ConditionAsthmaHypotensionObesityNone of Mentioned

*Did You Receive COVID-19 Vaccine? (required)
YESNO

If YES, Which One?
PfizerModernaOther

Vaccine Date 1st Dose (If applicable)

Vaccine Date 2nd Dose (If applicable)

*Where You Diagnosed with COVID-19? (required)
YESNO
Date of First Positive Diagnosis (If applicable):

Date of Last Negative Diagnosis (If applicable):

*Did You receive Monoclonal Antibody Infusion? (required)
YESNO
If YES, Which One?
BamlanivimabCasirivimab/Imdevimab
I understand that personal information will not be shared and will be kept confidential by Ayass BioScience, LLC. If If I am covered by insurance, I authorize Ayass BioScience, LLC to give my designated insurance carrier(s) plan on this form and other information provided by my health care provider necessary for reimbursement. I authorize Ayass BioScience, LLC to inform my Plan of my test results only if test results are required for preauthorization of or payment for reflex/additional testing. I authorize Plan benefits to be payable to Ayass BioScience, LLC. I further authorize payment of benefits directly to the laboratory. I understand acceptance of insurance does not relieve me from any responsibility concerning payment for laboratory services and that I am financially responsible for all charges whether or not they are covered by my insurance. I understand that any payment I receive for services rendered by the laboratory from my insurance provider should be forwarded immediately to the laboratory. I understand that if I don't have an insurance, I am financially responsible for all charges.
*I do consent for the remaining part of my sample to be used for research purposes by Ayass BioScience, LLC. (required)
YESNO
Security Question: 12+2?