SETLABS , LLC

Director : Loganathan Doraisamy Ph.D
CLIA:#
Phone :
Address :
Provider Name :
Dr PhilipMigrem ,MD
NPIA : 1407432289
Facility Info :Community wellness America, Inc
1150 Garden view Road PMB# 230174
Encinitas, CA 92023
(858)367-3435 or (858)461-8035(Espanol)
Electrically signed by the above named provider at the indicated collection time and date
PCR TEST MATCHING STICKER
RT-PCR TEST MATCHING STICKER
SARS-COV-2 Spe collection

1. Patient Information

Prefer Not To Say    Select

(Only 5 Numbers Allowed)
(Only 10 Numbers Allowed)

2. Patient Symptoms

In past 14 days you have experiened any of these? (Check any & all that apply)
Which of these symptoms do you have?
Increased Risk

Do Biofire Rapid Test

Health Questions
1. Have You Had Contact or Exposure To Someone With COVID-19?
yes No
2. Did That Person Have Symptoms?
yes No
3. Are You Employed In A Private or Public Frontline Worker?
yes No
4. Recently Traveled Out of Country?
yes No
5. Recently Visited A Hospital?
yes No
6. Recently Pregnant or Had Childbirth?
yes No

3.WHICH ARE YOU?

Insured    Uninsured

4.I agree for set Labs , LLC to perform my SARS-COV-2 PCR and /or RT-PCR Testing and send a Test result notice to me via text and/or email message . I have read and agree to the entire section “Consent for COVID-19 Diagnostic testing” on the backside of this form. All information I provide is true .If not I’m responsible for the texting fee cost .

Patient/Guardian Signature
Date