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

2. Patient Symptoms

(In past 14 days you have experiened any of these?)(Check any & all that apply)

3.WHICH
ARE YOU?

Insured

OR

Uninsured

Front
Back
Front
Back

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