Account Setup Form

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

Patient Information
Month: Day: Year:
No Email Provided








Michigan Questionnaire
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 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?