Advaite - SalivaDirect

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*

    Street Address*
    City*
    State*
    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*
    Type of specimen*

    Activation Code

    Collection Date*
    Collection Time*
    AM/PM*

    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.