SalivaDirect™ Kit Activation Please do not activate your kit until you are ready to ship your sample to our lab. First Name* Last Name* Date of Birth* Gender* MaleFemaleOther Street Address* City* State* ---AlabamaFloridaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyMaineMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNew JerseyNew MexicoNorth CarolinaNorth DakotaOhioOklahomaOregonRhode IslandSouth CarolinaSouth DakotaTennesseeUtahVirginiaWashingtonWest VirginiaWisconsinWyoming County* Zip Code* Home Phone Number* Cell Phone Number* Email Address* Race* Alaska NativeAmerican IndianAsianBlack or African AmericanHispanic or LatinoNative Hawaiian or other Pacific IslanderWhiteDecline to specifyOther Ethnicity* HispanicNon-HispanicDecline to specify Type of testing requested* ---SARS-COV-2 PCR Diagnostic Testing Type of specimen* ---Saliva Activation Code Collection Date* Collection Time* AM/PM* ---AMPM Patient Consent I consent to the collection of specimens for the purpose of testing, and certify that the tests ordered have been explained to me by an authorized health care provider. I understand that only tests ordered by a qualified provider will be performed. This sample may be stored indefinitely and used for internal test validation after personal identifiers have been removed. I also authorize lab to bill my insurance provider and to receive payment of benefits for the tests ordered by my physician. I further authorize lab and the ordering physician to release testing data to state or local public health department.