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Thank you for visiting HONU Management

Unfortunately this testing facility is no longer operating. Please visit your local state website to find another location that can assist you.
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Thank you for visiting HONU Management

We're sorry. This facility no longer utilizes the LTS preregistration link. Please visit the testing location to register.

Account Setup Form

1 Patient and Physician information
2 Testing Options

You have some form errors. Please check below.

Note: All information with a red asterisk ( * ) must be completed

Vehicle Information

License Plate Number

State

Make

Model

Take Photo of Vehicle License Plate

Schedule a Test *

Patient Information

Patients *

First Name *

Last Name *

Patient DOB *

Month: Day: Year:

DL/ID Number

Email *

No Email Provided

Phone Type *

Home

Mobile

Is Opt-in Text Messages

Phone No *

Secondary Phone Number

Address 1 *

Address 2

City*

State*

Zip Code*

County *

Add New County :

Gender *

Sex Assigned at Birth*

Male	Female	Non-binary
Transgender	Intersex	Prefer not to answer

Hispanic or Latino Ethnicity*

Hispanic or Latino	Non-Hispanic or Non-Latino
Prefer not to answer

Arab Ethnicity*

Arab	Non-Arab
Prefer not to answer

Race *

American Indian and/or Alaska Native

Asian

Black or African American

Native Hawaiian and/or Pacific Islander

White or Caucasian

Prefer not to answer

Middle Eastern or North African Descent

Other

Other Race*

Are you pregnant?

Yes

N/A

Facility Employee?*

Yes

Agricultural Worker?*

Yes

Received COVID-19 Vaccination?*

Yes, a complete series	Yes, a partial series
No vaccination	Prefer not to answer
Yes, booster(s)

Date of most recent COVID-19 Vaccine dose

University Affiliation

Student

Facility

N/A

Timing Component*

Abbott

Carestart

Indicaid

Other

Is Student*

Yes

Patient MRN*

Inmate Location*

Is Visitor*

Yes

Physician Order not Required

Physician Information

Physicians *

Michigan Questionnaire

Have you been in close contact (i.e. within 6 feet) with someone confirmed to have COVID-19?*

Yes

Unknown

Prefer not to answer

Have you attended a large group setting , public gathering, or congregation of people within the past (15) days?*

Yes

Prefer not to answer

Have you traveled anywhere outside of Michigan in the past 30 day?*

Yes

Prefer not to answer

I am a first responder.*

Yes

N/A

Do you live or work in a hospital, long-term care facility or assisted living facility?*

Yes

Prefer not to answer

Do you have a chronic health issue (such as diabetes, asthma, heart issues, etc.).*

Yes

Prefer not to answer

Please mark the symptoms you are currently experiencing:*

Fever	Muscle aches	Headache
Cough	Nausea and vomiting	Loss of taste and /or smell
Shortness of breath	Diarrhea	Tiredness, Fatigue
Sore throat	No Symptoms	Prefer not to answer
Other Symptoms

Specify:

How did you hear about the testing site?*

Website	Billboard	Radio Ad
Word of mouth	Social Media	Unsure/Don't Remember
Other

Specify:

Will you need language interpretation services when you are at the testing site? If so, what language?*

Please describe any additional assistance or accommodation you may need at the testing site. We will do our best to meet your needs. *

Do you live or work in a group home, assisted living center, day program or other facility with more than 3 other people older than 60 years old?

Yes

PATIENT SIGNATURE:

For non-touch screen devices, the patient needs to type their full name below, and provide a secondary identifier.

Add Signature

By selecting the Add Signature button, I attest that I approve of this digital signature

I hereby authorize the laboratory, Honu Labs, to collect, analyze, and report my results for my submitted specimens for testing. I understand that a biologic specimen (blood, urine, swabs, sputum, and/or saliva) will be obtained from me. I understand that this biologic specimen will be used for the purpose of identifying if I am infected with or identify if I am a carrier of COVID-19 (Coronavirus) and potentially other Respiratory Pathogens. I understand if I test positive for the infection, my results will be shared with the state according to the CDC and DHS regulations. I also understand that my employer is authorized to obtain my results. I understand that I may need to seek my medical provider’s opinion based on the results of my tests. I also understand that Honu Labs has telemedicine providers available if my medical provider is unavailable. I understand that testing negative may not be a definitive result for COVID-19, and I will continue to monitor my health for any changes. I understand that my specimen will only be used for the COVID-19 testing program as authorized by my consent and that my specimen will not be used in any identifiable fashion for research purposes without my consent. My signatures acknowledge my voluntary participation. I understand that the testing performed by Honu Labs is specific to this disease and in no way guarantees my health. Negative results do not preclude SARS-CoV-2 infection and should not be used as the sole basis for patient management decisions. Negative results must be combined with clinical observations, patient history, and epidemiological information.

I consent to have a COVID-19 test performed on myself/ a person on whose behalf I am entitled to provide consent (e.g. minors, wards). Read more

I consent to have a COVID-19 test performed on myself/ a person on whose behalf I am entitled to provide consent (e.g. minors, wards). I understand that the State of Michigan and MDHHS have partnered with HonuMG to provide community testing for COVID-19. I authorize the results to be sent to the ordering physician and to the facility where the test was conducted.

I consent to have a COVID-19 test performed on myself/ a person on whose behalf I am entitled to provide consent (e.g. minors, wards). Read more

I consent to have a COVID-19 test performed on myself/ a person on whose behalf I am entitled to provide consent (e.g. minors, wards). I understand that the State of Arkansas and MDHHS have partnered with HonuMG to provide community testing for COVID-19. I authorize the results to be sent to the ordering physician and to the facility where the test was conducted.

Billing Information

I decline to provide Insurance or do not have any insurance Benefits

Billing Type *

Client Bill	Commercial
Medicare	Medicaid
Worker's Comp DOI	Population Study
Self Pay

Illness/Accident Date

Month: Day: Year:

Accident Type

Accident State

Bill to:

Insurance

Patient Self-Pay

Relationship to Insured:

Self	Spouse
Dependent	Other

Clear Insurance

Subscriber Name

Policy Holder DOB *

Month:Day:Year:

Primary Insurance Provider

Insurance Name

Insurance Address

Insurance City

Insurance State

Insurance Zip Code

Primary Policy ID *

Primary Group ID

Insurance Phone #

Check Eligibility

Add Another Insurance

Please bring your insurance card to the test facility so it can be added to your chart

Take Photo of Insurance Card (Front) *

Take Photo of Insurance Card (Back) *

Medical Necessity *

Exposure to Covid-19

No of Days.

Signs and Symptoms

No of Days.

Cough (R05)

Shortness of breath (R06.02)

Fever unspecified (R50.9)

Employer/Agency Recommended Testing

Other.

Type of Registration.

Antigen Only

Antigen and PCR

COVID Questionaire

I have been exposed to someone infected with COVID 19.*

Yes

N/A

I am 65 years or older.*

Yes

N/A

I have been diagnosed by my medical provider with chronic health issues (such as diabetes, asthma, heart issues, etc.).*

Yes

N/A

I am a first responder.*

Yes

N/A

I am a DART driver, healthcare worker, or an employee of a critical infrastructure or public facing job

Yes

N/A

I have attended a large group setting, public gathering, or congregation of people within the past (15) days.*

Yes

N/A

Please select an option below if this applies to you*

Work in a health care or long-term care facility

Work or reside in a congregant living facility

Work in correctional facilities, such as jails or prisons

Work as a government employee

N/A

I have experienced the following symptoms within the past 30 days:*

headache and fatigue	Fever	Cough	Shortness of breath
Chills	Muscle pain	Loss of taste or smell	Sneezing
Runny or stuffy nose	Sore throat	Vomiting	Diarrhea
N/A

Have you used any of the following nasal antibiotic ointments in the past 24 hours: Mupirocin, Bactroban or Centany?*

Yes

N/A

Solv Questionnaire

Practice Name?

Reason for visit?

Have you experienced any of the above symptoms in the past 30 days?

I am currently experiencing the following symptoms (Select all that apply)?

I have attended a large group setting, public gathering, or congregation of people within the past (15) days?

I have been exposed to someone infected with COVID 19?

I have been diagnosed by my medical provider with chronic health issues (such as diabetes, asthma, heart issues, etc.)?

Pay with insurance?

Secondary phone number?

Testing Option

Source of information: https://www.cdc.gov/screening/

Home Test Kit

At Home Questionnaire

# Of boxes being picked up: *

Reason for obtaining tests (check all that apply): *

OTC tests are unavailable for purchase at local store	OTC tests are too expensive to purchase
Symptomatic	Known exposure
Requirement for work/school	Preparing for gathering with individuals [who may be high risk for severe disease]
Prefer not to answer

Is this a repeat pick-up or first time?*

First time

Repeat

Who will tests be used on?*

Self	Household member
Friend/Family outside the home	Prefer not to answer

If you had COVID-19 symptoms and did not have an at-home test kit, how likely is it you would go outside of the home to get tested? *

Very likely

Not likely

Prefer not to answer

My test results will help me make changes in my daily habits by (check all that apply):*

If positive, my results will inform me to take additional precautions to keep myself and others healthy and/or seek medical care
If negative, my test results will give me confidence in interacting with people and living my daily life
My test results will not affect my behavior
None of these apply
Prefer not to answer

If positive, my results will inform me to take additional precautions to keep myself and others healthy and/or seek medical care

If negative, my test results will give me confidence in interacting with people and living my daily life

My test results will not affect my behavior

None of these apply

Prefer not to answer

To help us improve on services offered at this location and other similar locations, please provide answers to the following questions:

Please check the additional health services you or your family member would use at this site if available:*

Blood pressure screening	Cholesterol screening
Diabetes screening	Immunizations (i.e. Influenza, HPV, Tdap Td, MMR, etc.)
Influenza testing	Mental and behavioral health screening
Mobile dentistry	Mobile mammograms
Prefer not to answer	None of these apply

Please check the counseling services you or a family member would use at this site if available:*

Domestic Violence counseling	Financial health counseling
Mental health counseling	Substance Use Disorder (tobacco, drugs and alcohol) counseling
Prefer not to answer	None of these apply

Please check the resource referrals you or a family member would use at this site if available:*

Childcare resources	Education resources (GED, financial management)
Food resources	Housing resources
Primary care provider (PCP) resources	Transportation resources
Prefer not to answer	None of these apply

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Michigan CBTI: Coopersville United Methodist Church

notifications

Thank you for visiting HONU Management

Thank you for visiting HONU Management

PATIENT SIGNATURE:

To help us improve on services offered at this location and other similar locations, please provide answers to the following questions: