MVL Testing

MVL Testing
Test Information
Confirm your test*

RT-PCRExpedited RT-PCRAbbott ID Now (NAAT)Antibody IgM & IgGCovid RT-PCR + Flu A/B + RSVUrinary Tract Infection qPCR
Which test is right for me?
Select your test turnaround time*
Note: "Same day" testing needs to be collected in morning.
Patient Information
First name*
Last name*
Date of Birth*

MonthDayYear
Gender*

MaleFemaleOther
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Phone*
Please enter a valid phone number.
Parent name (if patient is a minor)

First NameLast Name
Referral Information

A referral is required when purchasing a test. Please upload your physician's referral, or choose our prescription service referral method for a fee of $20.00
Choose a referral method*

Upload your referralMVL Prescription Service (additional $20)
Referring Institution*
Physician name *
Physician referral*

Please upload your physician's referral
Cancelof
Deliver report to Physician by*

EmailFax
Physician email
COVID-19 RNA Report will be delivered to this email
Physician fax
COVID-19 RNA Report will be delivered to this fax number
Test Information

Please select a date/time to perform the test.
Please Note: Peek Hours
The hours of 8–10am and 3–4pm tend to have a higher volume of appointments. Consider setting your appointment during non-peak hours to avoid wait time and higher traffic.
Preferred appointment for your test*
[HIDDEN] Appointment Time

Hour Minutes

AM/PM Option
[HIDDEN] Appointment Date

MonthDayYear
Date
Travel Information

Complete this section if you are taking the test for travel purposes.
I'm taking this test for travel
Specify the Country or State you will be traveling to
Date of International departure

MonthDayYear
Date
Hour MinutesAM/PM Option
COVID-19 History
In the last 14 days, has the patient experienced any COVID-19 symptoms?*

YesNo
If yes, please indicate which symptoms (Check all that apply)

Fever above 100°FChillsCough, shortness of breath, or difficulty breathingFatigueHeadacheMuscle or body achesNew loss of taste or smellSore throatCongestion or runny noseNausea or vomitingDiarrhea
Has the patient been in close contact with a known COVID-19 positive person or someone exhibiting any of the above symptoms?*

YesNo
If yes, what is date of exposure?

MonthDayYear
Date
Patient Consent

Please carefully read the following informed consent.
1. I authorize Molecular Vision Laboratory to conduct testing on the specimen I provide today.
2. I authorize my test results to be disclosed to the county, state, or to any other governmental entity as may be required by law.
3. I acknowledge that a positive test result is an indication that I must continue to self-isolate in an effort to avoid infecting others.
4. I understand that I am not creating a patient relationship with Molecular Vision Laboratory by participating in testing. I understand the testing unit is not acting as my medical provider. Testing does not replace treatment by my medical provider. I assume complete and full responsibility to take appropriate action with regards to my test results. I agree I will seek medical advice, care and treatment from my medical provider if I have questions or concerns, or if my condition worsens.
5. I understand that, as with any medical test, there is the potential for false positive or false negative test.
6. We may sequence the sample for pathogen sequences and report the pathogen sequences and other non-identifiable information such as viral variants to publicly accessible data bases, such as the GISAID and National Center for Biotechnology Information.
I, the undersigned, have been informed about the test purpose, procedures, possible benefits and risks, and I have received a copy of this Informed consent. I have been given the opportunity to ask questions before I sign, and I have been told that I can ask other questions at any time. I voluntarily agree to testing by Molecular Vision Laboratory.
Signature of Patient/Guardian*

Clear
Billing Information
[HIDDEN] PCR Price
[HIDDEN] Expedited PCR Price
[HIDDEN] Abbott ID NOW Price
[HIDDEN] Antibody IgM & IgG Test
[HIDDEN] PCR, Flu A/B, RSV Price
[HIDDEN] UTI Price
[HIDDEN] E-Prescribed add-to-cart value
[HIDDEN] Total
Total Amount Due
$20 fee has been added for MVL Prescription Service (selected above)
Payment method*

Credit, Debit, or HSA CardCash or Check
Your credit card will not be charged until services rendered.

Insurance requirements

A doctor's prescription is required when selecting Insurance as a payment method. Our MVL Prescription Service does not qualify you for insurance as a payment method.

Please take a photo (or upload) the front and back of your insurance card, as well as your photo ID. You can also provide this information at the time of specimen collection.
Insurance card (front)
Insurance card (back)
Photo ID
Please select a different payment method, or provide doctor's prescription.

A doctor's prescription is required when selecting "Insurance" as a payment method. Our MVL Prescription Service option (which you have selected above) does not qualify you for insurance as a payment method.
Please select a different preferred appointment for same-day testing

You have selected both "same day" turnaround time, and an appointment time after 12 noon. Sample collection for Same-day test results must be collected in the morning. Please select a preferred appointment before 12 noon, or select "Next day" turnaround time.
Insurance

Due to emergency authorization, insurance does not cover this test.
Should be Empty:

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

MVL Testing

Test Information

Patient Information

Referral Information

Test Information

Please Note: Peek Hours

Travel Information

COVID-19 History

Patient Consent

Billing Information

Insurance requirements

Please select a different payment method, or provide doctor's prescription.

Please select a different preferred appointment for same-day testing

Insurance