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

Vehicle Information
Patient Information
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Physician Order not Required
Physician Information
Testing Option
Specimen Information
Billing Information




Medical Necessity
READ AND INITIAL EACH STATEMENT BELOW AND SIGN FOR THE SERVICES YOU ARE REQUESTING
I understand that certain patient test results are required by law to be reported to federal, state and local health department for public health reasons. I understand it is my responsibility to consult with my doctor and/or contact my county health department main office.
I am age 18 or older. If <18, I am an emancipated minor or otherwise authorized to request and provide consent for the tests ordered below. If I am requesting testing for which a minor is required by law to consent the minor has consented to such testing.
I understand that it is solely my responsibility to promptly discuss all laboratory results with a physician and that neither the laboratories nor its Medical Director will provide interpretation, counseling, consultation, or care recommendations on the basis of any laboratory results provided to me. I release from liability and will not hold the laboratories or their directors responsible if I do not promptly communicate the results of these tests to my physician.

PHYSICIAN SIGNATURE:

Use Physician Signature
When ordering the tests, The physician is required to make independent medical decisions with regards to each test ordered. Only tests that are medically necessary will be reimbursed by the government or the private health plan. Read more

PATIENT/LEGAL REPRESENTATIVE SIGNATURE:

For non-touch screen devices, the patient/legal representative 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

I, the patient or legal representative, authorize Advanced Diagnostic Laboratory to perform testing and to release my test result to my health care provider and/or facility. I authorize Advanced Diagnostic Laboratory to obtain Read more
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PATIENT
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Medical Necessity
Infectious Disease Test Order
 
Physician Signature Not Available

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Patient Signature / Date