Register eLabx | Express Results | Get COVID testing services for yourself or your business

Covid Requisition Form

Test being requested: SARS-CoV-2 RNA (COVID-19), Qualitative NAAT

Please select testing location: *

Patient Assessment (choose one) *

Date of test/assessment *

Patient Information

Please answer all questions

First Name *

Middle Name

Last Name *

Date of Birth *

Sex *

Male

Female

Phone Number *

Please provide your social security number *

Your Contact Email *

Verify Your Email *

Address

Street Address *

Street Address Line 2

City *

State / Province *

Postal / Zip Code *

Do you have medical insurance? *

Yes, I do have medical insurance

No, I do not have medical insurance

What is the name of your insurance provider?

Medical Insurance - FRONT (Take or attach the picture of the front-side of it.) *

Medical Insurance - BACK (Take or attach the picture of the back-side of it.) *

** Image size should be less than 5mb. If using a smartphone, it will give you the option to take a picture of your card. Please make sure the card image is clear.

Results (typically 2-4 days)

To view your results, visit MyQuest Patient Portal. (link will be emailed to you upon completion of this form)
Follow instructions to either login or create a new account.
If your test comes back positive for the Covid-19 virus, you may be contacted via phone by the NC Department of Health and Human Services (DHHS) on how to proceed. Due to current volume, DHHS may not be able to contact everyone in a timely manner.
Additional communication may also be sent via email.

*Please keep in mind that communications via email over the internet are not secure. Although it is unlikely, there is a possibility that information you include in an email can be intercepted and read by other parties besides the person to whom it is addressed. By entering your email address, you agree to accept all risks.

Patient Agreement

The above information on all pages of this document is thorough and accurate to the best of my knowledge. For any changes to the above information, I will notify the eLabx (www.eLabx.com).

I consent to evaluation and treatment by any provider at Triangle Family Dentistry.
I hereby authorize release of medical information that is necessary for my further treatment.
I authorize release of information, including treatment and protected health information to my insurance company that is needed to process payment for services.
I authorize my insurance carrier to pay benefits for services rendered, directly to Triangle Family Dentistry or any of its affiliates.

I have read, understand and agree to the terms and conditions. I understand payment is expected for these services and that my insurance carrier will be billed on my behalf.

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