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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

Spanish Translation

Vehicle Information

State

Make

Model

Take Photo of Vehicle License Plate

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

Schedule a Test *

Patient Information

Patients *

First Name *

Last Name *

Patient DOB *

Month: Day: Year:

Passport #

License Plate Number

Email *

No Email Provided

Phone No *

Is Opt-in Text Messages

HomeMobile

Secondary Phone Number

Address 1 *

Address 2

City*

State*

Zip Code*

County *

Add New County :

Patient Occupation*

Job Title*

Did Patient visit school?*

YesNo

School District Name*

School Name*

School Job Class*

FacultyStaffStudent

Present in school 7 days a week

YesNoUnknown

Gender *

Sex Assigned at Birth*

MaleFemaleIntersexPrefer not to answer

Hispanic or Latino Ethnicity* Hispanic or LatinoNon-Hispanic or Non-Latino
Prefer not to answer

Arab Ethnicity* ArabNon-Arab
Prefer not to answer

Race * American Indian and/or Alaska NativeAsian
Black or African AmericanNative Hawaiian and/or Pacific Islander
White or CaucasianNot Listed
Prefer not to answer

Other Race*

Are you pregnant? YesNoN/A

Who is getting Tested?* School StudentSchool FacultyAll Other

Have you been vaccinated?* YesNo

Facility Employee?* YesNo

University Affiliation StudentFacilityN/A

Physician Order not Required

Physician Information

Physicians *

Michigan Questionnaire

Have you been in close contact (i.e. within 6 feet) with someone confirmed to have COVID-19?*

YesUnknownPrefer not to answer

Have you attended a large group setting , public gathering, or congregation of people within the past (15) days?*

YesNoPrefer not to answer

Have you traveled anywhere outside of Michigan in the past 30 day?*

YesNoPrefer not to answer

Do you live or work in a hospital, long-term care facility or assisted living facility?*

YesNoPrefer not to answer

Do you have a chronic health issue (such as diabetes, asthma, heart issues, etc.).*

YesNoPrefer not to answer

Please mark the symptoms you are currently experiencing:*

FeverMuscle achesHeadacheCough
Nausea and vomitingLoss of taste and /or smellShortness of breathDiarrhea
Tiredness, FatigueSore throatNo SymptomsPrefer not to answer
Other Symptoms

Specify:

Will you need language interpretation services when you are at the testing site? If so, what language?*

Please describe any additional assistance or accommodation you may need at the testing site. We will do our best to meet your needs. *

Do you live or work in a group home, assisted living center, day program or other facility with more than 3 other people older than 60 years old?

YesNo

Insurance Information

I have insurance coverage through an individual or family insurance plan
I do not have insurance coverage through an individual or family insurance plan
Cash Pay: I agree to pay the cash rate of $185 at the time of my appointment
Client Bill

Insurance Type *

OtherMedicareMedicaid

Relationship to Insured:*

Self	Spouse
Dependent	Other

Clear Insurance

Subscriber Name*

Policy Holder DOB*

Month:Day:Year:

Insurance Provider*

Insurance Carrier Not Listed.

Insurance Provider*

Insurance Address*

Insurance City*

Insurance State*

Insurance Zip Code*

Primary Policy ID *

Primary Group ID

Insurance Phone #

Social Security Number*

I do not have a Social Security Number

Photo ID*

Upload Photo ID, Driver License or Passport File

Photo Identification is required. Upload above or bring to your appointment.

Add Another Insurance

Check Eligibility

Insurance Cards*

Upload Photo of Front of Insurance Card

Upload Photo of Back of Insurance Card

Medical Necessity *

I may have been exposed to COVID-19 at school,work, or in my community (Z20.822).

Number of days since last exposure at school,work, or in the community

I am experiencing signs and symptoms of COVID-19

No of Days.

Cough (R05)

Shortness of breath (R06.02)

Fever unspecified (R50.9)

Loss of Taste/Smell (R43.9)

Employer/Agency Recommended Testing

Other.

Employer Information *

Employer Name*

Employer Street Address*

Employer City*

Employer State*

Employer Zip Code*

Employer Phone*

Clinic Questionnaire

I would not like to participate in questionnaire.

Do you have: Heart disease, High Blood Pressure, Lung disease, Asthma, Diabetes, or Kidney disease?*

YesNo

High Blood PressureLung Disease
Asthma DiseaseKidney Disease

Have you been exposed to Influenza A or B?*

YesNo

Are you outside of the recommended weight for your body structure?*

YesNo

Do you smoke?*

YesNo

Have you been exposed to Covid-19*

YesNo

Are you experiencing: fever, cough, shortness of breath, excessive fatigue, or muscle aches?*

YesNo

Solv Questionnaire

Practice Name?

Reason for visit?

Have you experienced any of the above symptoms in the past 30 days?

I am currently experiencing the following symptoms (Select all that apply)?

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

I have been exposed to someone infected with COVID 19?

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

Pay with insurance?

Secondary phone number?

Testing Option

PATIENT SIGNATURE:

PATIENT OR LEGAL GUARDIAN SIGNATURE (if patient is under 18, Parent or Guardian Signature is Required): Patient or Guardian Printed Name

Add Signature

Patient or Legal Guardian Name

I hereby authorize the laboratory, MMLAB , 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. Read more

I hereby authorize the laboratory, MMLAB Diagnostics, 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 authorize this site to release my medical information to any physicians and healthcare providers as well as adjusters, case managers, vocational counselors, employers, pharmacists, employers, school administrators and through email or text even if not be secure. I understand that I may need to seek my medical provider’s opinion based on the results of my tests.I also understand that MMLAB Diagnostics 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 LabLINQ Diagnostics 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.Patient gives authorization to Momentum Medical, the owner of the software used by LabLINQ Diagnostics, to participate in Momentum and LabLINQ's public health initiatives. I authorize Momentum and LabLINQ to keep and utilize specimens for data and testing advancements within the company. I authorize Momentum and LabLINQ to utilize my data for analytics with the exception of my first/last name, date of birth or direct contact information unless exceptions are specifically requested and granted. This consent authorization shall remain effective until revoked by me in writing.

I consent to have a COVID-19 test performed on myself/ a person on whose behalf I am entitled to provide consent (e.g. minors, wards). Read more

I consent to have a COVID-19 test performed on myself/ a person on whose behalf I am entitled to provide consent (e.g. minors, wards). I understand that the State of Michigan and MDHHS have partnered with MMLAB to provide community testing for COVID-19. I authorize the results to be sent to the ordering physician and to the facility where the test was conducted.

I consent to have a COVID-19 test performed on myself/ a person on whose behalf I am entitled to provide consent (e.g. minors, wards). Read more

I consent to have a COVID-19 test performed on myself/ a person on whose behalf I am entitled to provide consent (e.g. minors, wards). I understand that the State of Arkansas and MDHHS have partnered with MMLAB to provide community testing for COVID-19. I authorize the results to be sent to the ordering physician and to the facility where the test was conducted.

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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