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Testing Option

Specimen Information

Date of Collection *

Time of Collection *

PCR Specimen ID*

Type of PCR Specimen

Anterior NaresSaliva

Laboratory collected specimen

YesNo

Collector Name*

Medical Necessity

Exposure to Covid-19

Signs and Symptoms

No of Days.

Cough (R05)

Shortness of breath (R06.02)

Fever unspecified (R50.9)

Employer/Agency Recommended Testing

Z20.828 : Contact with and (suspected) exposure to other viral communicable diseases

Other.

School/University

Patient Type* StudentEmployee

School/University Location* On CampusOff Campus

Date of Return:*

ICD 10 Codes

Z03.818        Encounter For Observation For Suspected Exposure To Other Biological Agents Ruled Out
Z20.822        Contact With And (Suspected) Exposure To Covid-19
Z20.828        Contact With And (Suspected) Exposure To Other Viral Communicable Diseases

ICD 10 codes

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Description *

ICD 10 codes	ICD 10 code description	Action

Barcode

Generate Barcode

Barcode *

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.

Add Signature

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

Vehicle Information

License Plate Number

State

PATIENT

PROVIDER

First Name:

First Name

Last Name:

Last Name

DOB:

DOB

Gender:

Gender

Employee ID/DL:

Employee ID/DL

Email:

Phone No

Mobile Phone No

Country:

Country

Address:

Address

Address 2:

Address2

City:

City

State/Province:

State

Zip Code:

Zip Code

Barcode:

Barcode

Insurance Type :

Insurance Type

Illness/Accident Date

Illness/Accident Date:

Accident Type :

Accident Type

Accident State:

Physician Name:

Physician Name

NPI:

NPI

Insurance Detail

COLLECTION DETAILS

DIAGNOSTIC CODES

Ordered Date:

Date of Order

Time of Order:

Time of Order

Specimen Type:

Medical Necessity

Infectious Disease Test Order

Physician Signature / Date

Patient Signature / Date

Back

Self	Spouse
Dependent	Other

Session Expiration

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PHYSICIAN SIGNATURE:

PATIENT/LEGAL REPRESENTATIVE SIGNATURE: