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: FC24298492-1-19 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:
Nunez Ivan Eduardo
Address Line1: 10- 1151 Haro St Date of Birth: FCB Number: Address Line2: 791 King Edward Ave W 21-AUG-1990 FCB:90334549 City: Vancouver Province: BC Day Month Year
Postal Code: V5Z 2C7 Country: CA
Sex: M Telephone: 2368582183
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