Note: All information with a red asterisk ( * ) must be completed

Patient Information
Month: Day: Year:


Billing Information




PATIENT SIGNATURE:

For non-touch screen devices, the patient needs to type their full name below, and provide a secondary identifier.

By selecting the Add Signature button, I attest that I approve of this digital signature

By my signature below I voluntarily consent to the collection and testing of my specimen and the release of the testing results to the ordering physician/facility, however such results shall be used solely for clinical diagnostic/treatment purposes only and shall not be used for any forensic purposes related to my employment or other legal or administrative purposes. The specimen identified by this form is my own, is fresh and is unadulterated. Read more
PATIENT
PROVIDER
Insurance Detail
COLLECTION DETAILS
DIAGNOSTIC CODES
Infectious Disease Test Order
 
Physician Signature Not Available

Physician Signature / Date

logo

Patient Signature / Date