COVID SPECIMEN REQUISITION

CIAN Diagnostics Requisition Form - COVID-19 (SARS-CoV-2)
Last Name*
First Name*
Work site/residential site
Sex:*

MaleFemaleOther
Date of Birth*

MonthDayYear
Date
Patient STREET Address*
City*
State*
Zip Code*
Ethnicity*

HispanicNon-HispanicUndisclosed
Race*

AsianAmerican-IndianBlack/African AmericanIslanderWhiteUndisclosed
Phone #*
Collected By (type "self" or initials of person performing test)*
Is this your first test?*

YesNoUnknown
Are you employed in healthcare? (All DSPs answer yes)*

YesNo
Are you having symptoms?*

YesNo
If you answered yes, please pick the date your symptoms started

MonthDayYear
Date
Have you ever been hospitalized?*

YesNo
Have you ever been hospitalized in ICU?*

YesNo
Do live in congregate care? (All residents answer yes)*

YesNo
Are you pregnant?*

YesNoUnknown
I certify that 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. I further authorize a performing CLIA Laboratory to release the results of this testing to the treating authorized healthcare provider or facility.
Date

MonthDayYear
Date
Signature*

Clear
Should be Empty: