Account Setup Form

1 Patient and Physician information
2 Testing Options

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

Patient Information

Patients *

First Name *

Last Name *

Patient DOB *

Month: Day: Year:

DL/ID Number

No Email Provided

Phone Type

Home

Mobile

Is Opt-in Text Messages

Phone No *

Country *

Address 1*

Address 2

City*

State

Zip Code

County *

Gender*

Male

Female

Unknown

Intersex

Prefer not to answer

Ethnicity *

Hispanic/Latino	Non-Hispanic/Latino	Not Specified
Prefer not to answer

Race *

Asian	Black	White
American Indian/AK	Hawaiian/Pacific	Unknown
Not Specified	Other	Prefer not to answer

Other Race*

Are you pregnant?

Yes

Physician Order not Required

Physician Information

Physicians *

Specimen Information

Type of PCR Specimen

Blood	Mid-turbinate	Nasopharyngeal
Oropharyngeal	Saliva	Sputum
Urine

Medical Necessity

Exposure to Covid-19

No of Days.

Signs and Symptoms

No of Days.

Cough (R05)

Shortness of breath (R06.02)

Fever unspecified (R50.9)

Employer/Agency Recommended Testing

Other.

COVID Questionaire

I have been exposed to someone infected with COVID 19.

Yes

N/A

I am 65 years or older.

Yes

N/A

I have been diagnosed by my medical provider with chronic health issues (such as diabetes, asthma, heart issues, etc.).

Yes

N/A

I am a first responder.

Yes

N/A

I am a DART driver, healthcare worker, or an employee of a critical infrastructure or public facing job

Yes	No
N/A

I have attended a large group setting , public gathering, or congregation of people within the past (15) days.

Yes	No
N/A

Please select an option below if this applies to you

Work in a health care or long-term care facility	Work or reside in a congregant living facility
Work in correctional facilities, such as jails or prisons	Work as a government employee

I have experienced the following symptoms within the past 30 days:

headache and fatigue	Fever	Cough	Shortness of breath
Chills	Muscle pain	Loss or taste or smell	Sneezing
Runny or stuffy nose	Sore throat	Vomiting	Diarrhea

PATIENT SIGNATURE:

For non-touch screen devices, the patient 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 hereby authorize the laboratory, NovaDx, to collect, analyze, and report my results for my submitted specimens for testing. I understand that a biologic specimen (blood, urine, swabs, sputum, and/or saliva) will be obtained from me. I understand that this biologic specimen will be used for the purpose of identifying if I am infected with or identify if I am a carrier of COVID-19 (Coronavirus) and potentially other Respiratory Pathogens. I understand if I test positive for the infection, my results will be shared with the state according to the CDC and DHS regulations. I also understand that my employer is authorized to obtain my results. I understand that I may need to seek my medical provider’s opinion based on the results of my tests. I also understand that NovaDx has telemedicine providers available if my medical provider is unavailable. I understand that testing negative may not be a definitive result for COVID-19, and I will continue to monitor my health for any changes. I understand that my specimen will only be used for the COVID-19 testing program as authorized by my consent and that my specimen will not be used in any identifiable fashion for research purposes without my consent. My signatures acknowledge my voluntary participation. I understand that the testing performed by NovaDx is specific to this disease and in no way guarantees my health. Negative results do not preclude SARS-CoV-2 infection and should not be used as the sole basis for patient management decisions. Negative results must be combined with clinical observations, patient history, and epidemiological information.

Testing Option

Submit

Update

Thank you for submitting your order, an email has been sent with your order confimation number.

First Name *

Last Name *

Patient DOB *

Order # *

Women’s Health Panels

STD PANEL

Chlamydia/Chlamydia trachomatis
Gonorrhea/Neisseria gonorrhoeae
Haemophilus ducreyi
Creatinin Glucose
Herpes Simplex 1
Herpes Simplex 2
Mycoplasma genitalium
Trichomonas/Trichomonas vaginalis
Treponema pallidum

CANDIDIASIS PANEL

Candida albicans
Candida dubliniensis
Candida glabrata
Candida krusei
Candida lusitaniae
Candida parapsilosis
Candida tropicalis

AEROBIC VAGINITS PANEL

Staphylococcus aureus
Escherichia coli
Enterococcus faecalis
Group B Strep/S. agalactiae

BACTERIAL VAGINOSIS PANEL

Atopobium vaginae
BVAB2
Gardnerella vaginalis
Group B Strep/S. agalactiae
Lactobacillus crispatus
Lactobacillus gasseri
Lactobacillus jensenii
Lactobacillus iners
Megasphaera 1
Megasphaera 2
Mobiluncus mulieris
Prevotella bivia
Mobiluncus curtisii
Mycoplasma hominis
Ureaplasma urealyticum

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PATIENT SIGNATURE: