Order Form | Nova Diagnostics Labs

Patient Information / 检测人信息

First Name / 名 *

Middle Name / 中间名

Last name / 姓 *

DOB / 生日（月/日/年） *//

Gender / 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 *

Email

Confirm Email

Location *

Nova Connect (Nova联系人) *

Ethnicity / 人种 *

Hispanic / Latino
Not Hispanic / Latino
Other

Race / 人种 *

Attach 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) *

Date / 签字日期 *

Patient Information / 检测人信息

DISCLAIMER: By signing below, the patient is aware of the following:

NOVA Diagnostics Labs

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