DAT収集のオンライン認証 「*」は必須フィールドを示します I understand that the address written on the test requisition form, which may be my primary residence, is within a state not currently eligible for Direct Access Testing (DAT). This attestation verifies that I collected my specimen within the approved DAT state written below. I also verify that I placed the provided paperwork in the provided biohazard bag and then placed both in a return shipping package that was given to an office or driver. DAT States: AK, AR, AZ, DE, IN, IA, KS, LA, MN, MS, MO, MT, NE, NM, NC, ND, OH, OK, SD, UT, VT, WA, WV, WI, TX, VA, District of Columbia.Name* 名 姓 Date of Birth* MM スラッシュ DD スラッシュ YYYY Email Sample Date of Collection* MM スラッシュ DD スラッシュ YYYY Accession ID*State of Sample Collection*Please SelectAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificSignature of Patient or Patient's Legally Authorized Representative Date* MM スラッシュ DD スラッシュ YYYY Printed Name of Legally Authorized Representative (if applicable) 名 姓 Relationship to Patient
