Laboratory Requisition Form

Complete this form ONLY if you have purchased our COVID-19 Test Packet. Note: All details MUST match the information provided with the COVID-19 Test Packet you mailed to our lab.
  • Date Format: MM slash DD slash YYYY
  • Patient Details

  • Date Format: MM slash DD slash YYYY
  • PHYSICIAN / HEALTHCARE PROVIDER (MD / NP)

  • Your test results may be a permitted disclosure under HIPAA. We are required to disclose your personal health information to public health authorities to the extent relevant to that authority. This includes disclosing positive test results for COVID-19 to state and local health departments, HHS, or the CDC as appropriate.
  • This field is for validation purposes and should be left unchanged.