Account Setup Form
Patient Information
Month: Day: Year:
No Email Provided

Insurance Information

Medical Necessity *
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?


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

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