Laboratory Requisition Form (Saliva Test)

Laboratory Requisition Form (Saliva)

Complete this form ONLY if you have purchased our COVID-19 SALIVA Test Packet. Note: All details MUST match the information provided with the COVID-19 Test Packet you mailed to our lab.

Collection Date*
MM slash DD slash YYYY
Time

: Hours

Minutes
Barcode Number (sent with your Test Packet)*
Where Purchased*
Hidden
Patient Details
First Name*
Middle Intital
Last Name*
Date of birth*
MM slash DD slash YYYY
Mobile Number*
Personal Email Address*
Address*
Street Address Address Line 2 City State ZIP Code
Gender*
- Male
- Female
Can sample be used for research purposes?
- Yes
- No
Patient or Parent/Guardian (if patient is under 18) Acknowledgement:
I acknowledge that I am voluntarily submitting an oral swab sample for COVID-19 to EnMed MicroAnalytics, Inc / Phi Life Sciences. I acknowledge that the informatiom provided by me is true to the best of my knowledge.
ORGANIZATION INFORMATION
Organization Name
Phone
Address
Street Address Address Line 2 City State ZIP Code
Contact Name
Position
Email
ORDERING MEDICAL PROFESSIONAL (MANDATORY)
Name
NPI Number
Email
Address
Street Address Address Line 2 City State ZIP Code
CONFIRMATION OF INFORMED CONSENT AND STATEMENT OF MEDICAL NECESSITY
I hereby confirm that the test(s) are medically necessary for the treatment and/or plan of care for the patient. I further hereby confirm that the information has been supplied about SARS-CoV-2 and that an appropriate EnMed MicroAnalytics, Inc and Phi Life Sciences Informed Consent has been signed by the patient and is on file with the ordering health care professional.
Date*
MM slash DD slash YYYY
Name*
First Last
Email
This field is for validation purposes and should be left unchanged.

Laboratory Requisition Form (Saliva)

Patient Details

ORGANIZATION INFORMATION

ORDERING MEDICAL PROFESSIONAL (MANDATORY)