Order Form

Minor Consent Section:

Parental Consent for Minor

for sample collection and laboratory testing

I/We Parent(s)/Guardian name

give authorization to collect a Nasopharyngeal swab sample on my minor (under 18) at Lab District, located at 3911 Hollywood Blvd, Suite 202, Hollywood, FL 33021, for the purpose of testing my child for COVID-19 by PCR method.

Minor Child's Name:

Date of Birth

Questionnaire:

In the last two weeks have you been around anyone who could be infected with COVID-19?

Yes No

Have you traveled outside the U.S. in the last 6 months?

Yes No

Have you done similar testing in any other place today?

Yes No

Have you been social distancing?

Yes No

Employed in health care setting?

Yes No

In the last two weeks have you experienced any of the following symptoms?