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First Name:
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Last Name:
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Email Address:
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Retype Email Address:
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Phone Number:
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Institution:
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Title:
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Address:
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City:
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State:
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Country:
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Zip/Postal Code:
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I practice/work in: (select all that apply)
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Emergency
Hospital
Urgent Care
Primary Care
Pharmacy
Specialized Clinic
Long-term Care/Nursing Home
Other Clinical Setting
Medical Distributor/Manufacturer/Supplier (if 'yes', you may skip the following question)
Non-clinical Setting
Other
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I specialize in: (select all that apply)
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Pediatrics
Family Medicine/Internal Medicine
Laboratory
Emergency Medicine
Urgent Care
Student/Resident
Administration
Pharmacy
Other area of clinical care
Operations/Practice Management
Other
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My credentials (i.e., MD, RN, PhD, etc.) are:
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We currently have the following urinary antigen tests available: (Select all that apply)
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Legionella pneumophila
Streptococcus pneumoniae
Don’t know
Not applicable/Not a patient care or laboratory site
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