COVID-19 PCR SWAB TEST REQUISITION

Please book your appointment at one of the participating retail locations at

https://www.lifelabs.com/FlyClear/#locations
You CANNOT visit a LifeLabs location for PCR swab testing through FlyClear
FlyClear
Laboratory Requisition
ORDER ID: FC404759-1-12 This requisition form, when completed, constitutes
a referral to LifeLabs laboratory physicians

Test Summary Label Client Summary Label Demographic Label

Bill to Account #: AD355 Account Name: F LYC LE AR

Patient Surname: First:
Date of Birth: FCO Number:
Keteloglu Zeynep 04-F E B-1998 F C O :24420
Address Line1: 168 Euclid Av e Day Month Year

Address Line2:
Sex:
City: TORONTO Province: ON
F
Postal Code: M6J 2J9 Country: CA

Telephone: 6479144024

Ordering Physician Last Name: First: Specimen Collected by:

Title: FLYCLEAR
REPORT TO:AD35501 Date: YYYY/ MM/ DD
Address Line 1:100 INTERNATIONAL BLVD
Time (24h time): HH:MM
Address Line 2:ATTN: DR. DON WAUCHOPE
City: ETOBICOKE Province: Ontario
Store #:
Postal Code: M9W 6J6 Country: Canada

The requisition is for Covid-19 only; additional tests cannot be added.

Tests Requested:
C ovid-19 Mnemonic = C V19P
Site: Bilateral Nasal Swab

In Client Reference Number, Enter FCO number using format FCO:### (located above barcode)

We collect, use, and disclose your personal informa on and personal health informa on in accordance with applicable privacy laws. We only collect and use your personal informa on and personal health informa on: to
verify your iden ty; accurately match your specimen with your results; follow-up for tes ng; enable payment; use of specimen for quality assurance; and to book and confirm appointments. We may also use popula on-
level, aggregate informa on to evaluate our performance, contribute to health system improvement, and to support research. We disclose your results informa on to LifeLabs healthcare prac oners. If we are asked to
disclose personal health informa on about you for another reason, other than as required or permi ed by law, we will contact you to obtain your consent. For addi onal informa on on our personal informa on handling
policies and prac ces, your rights, and point of contact for any further inquiries, please visit our privacy policy at https://lifelabs.com/privacypolicy/. For more informa on, also see our FAQs at
https://www.lifelabs.com/flyclear. Samples may be referred to a testing laboratory outside of Canada. By agreeing to move forward with the laboratory test, you agree to the terms set out above.

This LifeLabs requisition is valid within Ontario only

Ver: Nov 2020