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 SIGNATURE:

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, LabLINQ , 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