2001 E. First St Suite 109 Santa Ana, CA 92705 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 Information / 检测人信息First Name / 名 *Middle Name / 中间名Last name / 姓 *DOB / 生日(月/日/年) *MM123456789101112/DD12345678910111213141516171819202122232425262728293031/YYYY20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Gender / 性别 *M / 男F / 女Address / 地址 *City / 城市 *State / 州 *Zip Code / 邮编 *MRN (Passport Number) / 护照号码/旅行证号码 Will you be using insurance? 你会使用保险吗? *Yes, I will be using insurance. 是的,我会使用保险.No, I will not be using insurance. 不,我不会使用保险.Note: If you choose to use your insurance, then you will be required to pay a $20.00 service fee. 注意:如果您选择使用保险,则需要支付20.00美元的服务费.Phone / 美国电话 *Your Email address: / 电子邮件地址 *EmailConfirm EmailLocation *Please selectSanta AnaNova Connect (Nova联系人) *Walk InSheilaCindyEthnicity / 人种 *Hispanic / LatinoNot Hispanic / LatinoOtherRace / 人种 *American Indian/Alaska NativeBlackAsianLatinoNative Hawaiian/Pacific IslesWhiteUnknownAttach Files / 上传资料 (护照照片页) 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 / 签字 (中英文都可以) *Clear SignatureDate / 签字日期 *EmailSubmit “Results You Can Trust”