Requisition form (UTI, STD, FLU, GI, PGX, RPP)

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Patient Information

Patient Last Name *

Patient First Name *

Date of birth (MM/DD/YYYY)
*

YYYY

Phone
*

Address
*

City *

State *

Postal Code *

Collection Date & Time
*

YYYY

Time

Sex *

Female

Male

Intersex

Decline to Answer

Other:

Gender Identity
*

Female

Male

Transgender Female

Transgender Male

Non-binary/ gender fluid

Decline to Answer

Other:

Race *

American Indian / Alaskan Native

Asian

Black / African American

Native Hawaiian/ Pacific Islander

White

Decline to Answer

Other:

Ethnicity
*

Hispanic

Not Hispanic

Decline to Answer

Other:

Physician Information
*

Name, Email, Practice Name

Send Results to: *

Patient Email

Physician Email

Both

Other:

Test Required & Sample Type *

UTI PCR PANEL (Sample Type: Human Urine)

STD PCR PANEL (Sample Type: Human Urine)

GI PCR PANEL (Sample Type: Fecal Swab)

COVID, Flu A + Flu B + RSV PCR PANEL (Sample Type: Nasopharyngeal Swab)

RPP PCR PANEL (Sample Type: Nasopharyngeal Swab)

PGX PANEL (Sample Type: Human Buccal Swab (x3))

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