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 certify that I have voluntarily provided fresh and unaltered specimen for testing. The information provided on this form and on the label affixed to the specimen is accurate. I hereby authorize Advaite Inc UIC incubator Laboratory to release the laboratory testing data directly to state or local public health departments. I agree that this specimen is provided voluntarily for analysis. I authorize Advaite Inc UIC Incubator Laboratory or its assignee to process and administer results as per the policy.