False Positive COVID-19 Test Dispute Form
Submit your details to dispute a false positive COVID-19 test result. Please provide accurate information to help us review your case efficiently.
Full Name
*
First Name
Last Name
Preferred Contact Method
*
Email
Phone
Email Address
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Date of COVID-19 Test
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Type of COVID-19 Test
*
Please Select
PCR
Rapid Antigen
Other
Test Result Being Disputed
*
Positive
Inconclusive
Reason for Dispute
*
Upload Supporting Evidence (optional)
Upload a File
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Choose a file
Cancel
of
Desired Resolution
*
Submit Dispute
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