5252 Orange Avenue, Ste. 101 Cypress, CA 90630 Tel: 833-668-2522 Fax: 833-668-2329 Lab Director: Rosaura Williams, MD CLIA #: 05D0871568 PATIENT IDENTIFICATION WITHOUT PROPER IDENTIFICATION, TESTING CANNOT BE PERFORMED. ATTACH A COPY OF IDENTIFICATION PLEASE. Identification type: (Driver License, Passport, Identification Card, etc) Please enable JavaScript in your browser to complete this form.Patient InformationFirst Name / 名 *Last Name / 姓 *DOB / 生日(月/日/年) *MM123456789101112/DD12345678910111213141516171819202122232425262728293031/YYYY202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Gender / 性别 *M / 男F / 女Service Requested... *Standard ServiceRush Service (3 to 4 hours)(Prices Vary, Please call if not sure)TRN #OptionalHow Did You Hear About Us?OptionalPhone / 电话 *Location/Client (Please keep Other selected, if you are not sure about location) *Please selectNova Walk In CypressOtherAshe SocietyBetter Urgent CareFuya VisionGolden SailHunterIrvine MailboxQuikturnSnapoomAddress / 邮寄地址 *City / 城市 *State / 州 *Zip Code / 邮编 *Ethnicity / 人种Ethnicity / 人种 *American Indian/Alaska NativeBlackAsianLatinoNative Hawaiian & Other Pacific IslanderWhiteMulti-RaceOtherRace *American Indian/Alaska NativeBlackAsianLatinoNative Hawaiian/Pacific IslesWhiteUnknownPAYMENT INFORMATIONPAYMENT INFORMATION *CASHCREDIT CARDI agreePay on site, before sample collectionSELECT TEST TO BE PERFORMED / 测试类型 *SARS-CoV-2 [COVID-19] by Nucleic Acid RT-PCR (nasopharyngeal swab w/VTM)SARS-CoV-2 [COVID-19] IgG/IgM Antibody by ELISA (serum)METHOD OF RECEIVING PATIENT TEST RESULTS: *EMAILFAXYour FAX Number *Your Email address: / 电子邮件地址 *EmailConfirm EmailAttach files Click or drag files to this area to upload. You can upload up to 5 files. Max File Size 10 MB DISCLAIMER: By signing below, the patient is aware of the following: This test has been validated by Nova Diagnostics Laboratories and utilizes the FDA approved method under the Emergency Use Authorization (EUA). Molecular diagnostic testing by PCR should be considered to rule out infection at the time of collection. The COVID-19 molecular diagnostic test relies on the accurate collection of the specimen; improper collection may compromise the outcome of the test results. Test results will only be delivered by the method indicated by the patient; if the results are to be emailed to the patient, patient signature is required. Nova Diagnostics Labs strictly follows HIPAA guidelines and will only send the test results by the method the patient chooses, as indicated above. All patients’ COVID-19 test results will be reported to the California Department of Public Health (according to CDC guidelines). Patient Signature *Clear SignatureDateWebsiteSubmit “Results You Can Trust”