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Vaccination Registration
BHW LLC dba BHW Diagnostics, Benson, NC - CDC CLIA# 34D2187512
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* Indicates required question
Register only ONE Person at a Time.
Mark the box for the Test you are having done today for?
Rapid Antigen Covid-19 Test
Covd-19 Antibodies Test
Flu Test
Moderna Vaccine or Booster
Enter the First Name of the Client:
*
Your answer
Middle Initial
Your answer
Last Name
*
Your answer
Enter the Client's Date of Birth (00/00/0000)
*
Your answer
Enter the Client's Drivers License or ID Number
*
Your answer
Select the Client's Gender:
*
M
F
Other:
Enter the Client's Mailing Street Address
*
Your answer
City
*
Your answer
Enter a 2 letter State (eg. NC)
*
Your answer
ZipCode
*
Your answer
Enter the Client's Ethnicity
*
Choose
Black
White
Hispanic Latino
Asian Pacific Islander
Undisclosed
Enter the Client's Phone Number with Area Code
*
Your answer
Enter the Email to submit results or communication:
Your answer
Is the Client a Minor (under 18 years of age)?
*
Yes
No
Relationship to Client
*
Choose
Parent
Grandparent
Lab Helper
Self
Legal Guardian
Spouse or Partner
Sibling
Interpreter
Name of Person Completing this Registration Form
*
Your answer
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