COVID-19 Home Test Order Request

Have you received an OTC COVID-19 test(s) in the current calendar month?*

YesNo
If yes, please enter the number of OTC COVID-19 test(s) received in the current calendar month? *
I, {patientName}, am requesting to receive up to eight (8) tests per month.

By agreeing, you are authorizing Advanced Diagnostic Lab to be your preferred provider for eight (8) at-home COVID-19 tests each month for the duration of the Public Health Emergency (PHE). *

You acknowledge that insurers may cover up to 8 at-home COVID-19 tests per person each calendar month. Requests exceeding this amount may be billed directly to the patient.
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First Month Order Quantity

How did you hear about us?
Please enter the name of person, provider or organization.
CPT
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Date

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