COVID-19 PCR Laboratory Order Form
Patient Information
Full Name
Date of Birth
Gender
Male
Female
Other
Address
Phone Number
MRN (Medical Record Number)
Test Information
Reason for Test
Symptoms
Exposure
Pre-op
Travel
Other
Date Collected
Specimen Type
Nasopharyngeal Swab
Oropharyngeal Swab
Saliva
Other
Clinical Information / Symptoms
Ordering Physician
Physician Name
Phone
NPI#
Additional Notes