COVID-19 PCR Test Requisition Form
I certify that the information provided on this form is accurate. I authorize dNTP Laboratory ("the lab") to release the results of this test to the ordering provider. I further authorize the lab to bill my insurance and to receive payment of benefits for the test ordered. I authorize the lab to release to my insurance provider any medical information necessary to process this claim. If the insurance is inactive on the date of service, I agree to pay the bill provided by the lab.
Thanks for the order. We'll get back to you soon.