Account Setup Form

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

Patient Information
Month: Day: Year:



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:



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