COVID-19 PCR/NAAT SWAB TEST REQUISITION

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

https://www.lifelabs.com/flyclear/predeparture/#locations
You CANNOT visit a LifeLabs location for PCR/NAAT swab testing through FlyClear
FlyClear
Laboratory Requisition
Order ID: LL00007471782-S4 This requisition form, when completed, constitutes
a referral to LifeLabs laboratory physicians

Test Summary Label Client Summary Label Demographic Label

Bill to Account #: A8572 Account Name: FLYCLEAR

Patient Surname: First: Middle:

CHIANG HO-EN
Address Line1: 6000 Buckingham AVE Date of Birth: FCB Number:
Address Line2: 09-OCT-2004 FCB:205116977
City: Burnaby Province: BC Day Month Year

Postal Code: V5E2A4 Country: CA

Sex:
M
Telephone: 6046550686

Ordering Physician Last Name: First: Specimen Collected by:

Title: Dr. SEGAL GRAHAM
MSC Number:DB59351 Date: -------/-------/-------
DD MMM YYYY
Address Line 1:3680 GILMORE WAY
Time (24h time): ------:------ HH:MM
Address Line 2:FLYCLEAR COVID19
City: BURNABY Province: British Columbia
Store #:
Postal Code: V5G 4V8 Country: Canada

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

BC LifeLabs Staff Enter:

In Field 1 and 2, enter Collection Date and Collection Time as per requisition
In Field 11 (Global Comments) Enter:“CONTRACT CLIENT
CHART Field:
Enter FCB number located above barcode exactly as indicated. Start with FCB: and include all digits.
TEST: COVID-19
Enter appropriate mnemonic with test level comment:
”NASAL.’ACCOUNT.”COLLECTED DD-MMM-YYYY
If Site Prompt present, enter: NAS
Billing Screen:
At Enter Account Information Field , enter the Order ID located top center of requisition exactly as indicated. Start with FC and enter all digits and dashes.
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. Posi ve Covid test result is also reported to local public health authority for contact
tracing. 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/predeparture. In some instances, samples may be referred to a tes ng laboratory outside of Canada to ensure mely processing of samples. By agreeing to move forward with the laboratory test, you agree to
the terms set out above including disclosure of link to results to the email address you provided at the time of registration.

This LifeLabs requisition is valid within British Columbia only

Ver: Sep 2021