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* Date Format: MM slash DD slash YYYY Time : HH MM AM PM Barcode Number (sent with your Test Packet)*Where Purchased*Patient DetailsFirst Name*Middle IntitalLast Name*Date of birth* Date Format: MM slash DD slash YYYY Mobile Number*Personal Email Address* Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Gender*MaleFemaleCan sample be used for research purposes?YesNoPatient 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 INFORMATIONOrganization NamePhoneAddress Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Contact NamePositionEmail ORDERING MEDICAL PROFESSIONAL (MANDATORY)NameNPI NumberEmail Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific 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* Date Format: MM slash DD slash YYYY Name* First Last PhoneThis field is for validation purposes and should be left unchanged.
