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I understand that certain abnormal test values are considered “critical” because they may (but do not necessarily) indicate the presence of a potentially life threatening condition requiring immediate medical attention. I understand that Sonora Quest Laboratories will notify me by phone of any critical result upon completion of testing, at any time of the day or night.
Read and initial each statement below and digitally sign for the services you are requesting through My Lab ReQuest.
I am requesting Direct Access Testing through My Lab ReQuest. I do not have a physician order for these tests. I understand that only I will receive the testing results. Sonora Quest Laboratories may share the test results with my physician or other providers only in critical or emergent situations or as required by law.
I understand that certain patient test results are required by Arizona Administrative Code (R9-4-302 and 404.H. and R9-6-204) to be reported to the Arizona Department of Health Services (AZDHS) for public health reasons. For selected results marked with an * on the test menu, a local or state public health investigator may contact me for additional information or to ensure proper treatment. If I receive a positive test result for a sexually transmitted disease or tuberculosis, I understand it is my responsibility to consult with my doctor and/or contact my county health department’s STD clinic or main office.
I am age 18 or older. If <18, I am an emancipated minor or otherwise authorized to request and provide consent for the tests ordered below. If I am requesting testing for which a minor is required by law to consent (noted below by ^), the minor has consented to such testing.
I understand that Arizona law prohibits laboratories from billing health insurance for patient ordered laboratory testing. I further understand that these tests are not covered by Medicare as Medicare does not cover laboratory testing without a physician order. Full payment is due at time of service.
I understand that it is solely my responsibility to promptly discuss all laboratory results with a physician and that neither Sonora Quest Laboratories nor its Medical Director will provide interpretation, counseling, consultation, or care recommendations on the basis of any laboratory results provided to me. I release from liability and will not hold Sonora Quest Laboratories LLC or its Medical Director responsible if I do not promptly communicate the results of these tests to my physician.
Patient or Legal Guardian Digital Signature
Your laboratory test request form will be valid for 60 days.
Print your laboratory test form and take it with you to any of our Patient Service Centers located conveniently throughout Arizona.
While appointments are not required at most locations, you can schedule an appointment now to help you save time.
Follow instructions on the form if fasting is required for the testing you are ordering.
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