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

Vehicle Information
Patient Information
Scan DL/ID
Month: Day: Year:
Home Phone number
Physician Order not Required
Billing Information




Specimen information
Medical Necessity

Please Select Insurance Type and add Primary Insurance Provider for Testing Options

Testing Option

PHYSICIAN SIGNATURE:

As part of my antibiotic stewardship policy, I find it medically necessary to rapidly determine and differentiate a viral and/or bacterial infection in order to treat with or without appropriate antibiotics. Having the most accurate and timely data available to me directly guides my treatment and patient management. Read more

PATIENT SIGNATURE:

For non-touch screen devices, the patient 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 certify that I have voluntarily provided a fresh and unadulterated specimen for analytical testing. The information provided on this form and on the label affixed to the specimen is accurate. Read more
Vehicle Information
PATIENT
PROVIDER
Insurance Detail
COLLECTION DETAILS
DIAGNOSTIC CODES
Medical Necessity
Infectious Disease Test Order
 
Physician Signature Not Available

Physician Signature / Date

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Patient Signature / Date