Account Setup Form

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

Patient Information
Month: Day: Year:
No Email Provided








Michigan Questionaire
Have you been in close contact (i.e. within 6 feet) with someone confirmed to have COVID-19?
Have you attended a large group setting , public gathering, or congregation of people within the past (15) days?
Have you traveled anywhere outside of Michigan in the past 30 day?
Do you live or work in a hospital, long-term care facility or assisted living facility?
Do you have a chronic health issue (such as diabetes, asthma, heart issues, etc.).
Please mark the symptoms you are currently experiencing:




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

PATIENT SIGNATURE:

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

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. Read more
Medical Necessity
COVID Questionaire
I have been exposed to someone infected with COVID 19.
I am 65 years or older.
I have been diagnosed by my medical provider with chronic health issues (such as diabetes, asthma, heart issues, etc.).
I am a first responder.
I am a DART driver, healthcare worker, or an employee of a critical infrastructure or public facing job
I have attended a large group setting , public gathering, or congregation of people within the past (15) days.
Please select an option below if this applies to you


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



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?