* must provide value
Swab and Send-MaineHealth-Brunswick Swab and Send-MaineHealth-Damariscotta Swab and Send-MaineHealth-Farmington Swab and Send-MaineHealth-Norway Swab and Send-MaineHealth-Rockport
*State Requisition Form
Please do not use punctuation marks when typing your name (example: . ' -) * must provide value
*State Requisition Form
* must provide value
*State Requisition Form
*State Requisition Form
* must provide value
Today M-D-Y *State Requisition Form
* must provide value
Site information only, not included in state form.
Are we authorized to leave a message with results on ______ ______ 's phone number provided ( ______ )
No Yes
Site information only, not included in state form.
For verification purposes, please enter your email again
Site information only, not included in state form.
Email is required. Test results will be sent via email
The email addresses you entered above do not match (First entry ______ . Second entry ______ . Please update until you do not see this error. Are we authorized to email ______ ______ 's results to ______
No Yes
Male Female Transgender M-F Transgender F-M Not Specified Unknown
*State Requisition Form
* must provide value
American Indian or Alaskan Native Asian Black or African American Native Hawaiian or other Pacific Islander Not Specified Some other race Two or more races White
*State Requisition Form
* must provide value
Hispanic or Latino Non-Hispanic or Latino Not Specified
*State Requisition Form
* must provide value
*State Requisition Form
* must provide value
*State Requisition Form
* must provide value
AK AL AR AS AZ CA CO CT DC DE FL FM GA GU HI IA ID IL IN KS KY LA MA MD ME MH MI MN MO MP MS MT NC ND NE NH NJ NM NV NY OH OK OR PA PR PW RI SC SD TN TX UM UT VA VI VT WA WI WV WY 67 71 76 79 81 84 86 89 95
*State Requisition Form
* must provide value
*State Requisition Form
*Read-only for state eTOR file.
Pregnant Yes No Unknown
*State Requisition Form
Estimated Due Date Today M-D-Y *State Requisition Form
Patient preferred language, if not English *State Requisition Form
*State Requisition Form
*State Requisition Form
*State Requisition Form
Phone Number *State Requisition Form
Fax Number *State Requisition Form
Email *State Requisition Form
* Specimen Collection Date and Time
* must provide value
Now M-D-Y H:M *State Requisition Form
Specimen Collection Month Must be the same month as the Specimen Collection date entered above: ______ .
* must provide value
January February March April May June July August September October November December
Required for State eTOR CSV/Excel File export and the Upcoming scheduled appointments report function.
Specimen Collection Day Must be the same day as the Specimen Collection date entered above: ______ .
* must provide value
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
Required for State eTOR CSV/Excel File export and the Upcoming scheduled appointments report function.
Specimen Collection Year Must be the same year as the Specimen Collection date entered above: ______ .
2020 2021
Required for State eTOR CSV/Excel File export and the Upcoming scheduled appointments report function.
SARS-CoV-2
*State Requisition Form
ICD-10 Code(s)/Diagnosis U07.1 COVID-19 acute respiratory disease
*State Requisition Form
Anterior Nares (nasal swab) Nasal mid-turbinate (nasal swab) Nasopharyngeal Oropharyngeal (Throat) Other
*State Requisition Form
If other, specify *State Requisition Form
Supervised onsite self-collection Yes No
*State Requisition Form
Yes No
*State Requisition Form
If Yes, Facility Name?* must provide value
Swab and Send-MaineHealth-Brunswick Swab and Send-MaineHealth-Damariscotta Swab and Send-MaineHealth-Farmington Swab and Send-MaineHealth-Norway Swab and Send-MaineHealth-Rockport
As a state requirement, please select your facility name. The facility name you select must match the *Facility name selected at the top of this form (i.e., ______ ).
Yes No
*State Requisition Form
If Yes, Facility Name? *State Requisition Form
First Responder (Police, Fire, EMS)? Yes No
*State Requisition Form
If Yes, Organization? *State Requisition Form
Congregate Setting (LTC, Jail, shelter, farm, etc)? Yes No
*State Requisition Form
If Yes, Facility Name? *State Requisition Form
Patients older than 60 years? Yes No
*State Requisition Form
Patient (Symptomatic\Asymptomatic)? Symptomatic Asymptomatic
*State Requisition Form
Symptoms (please use comma to separate values):
Fever or chills
Fatigue
Headache
Nausea or vomiting
Cough
Muscle or body aches
Sore throat
Diarrhea
Shortness of breath or difficulty breathing
New loss of taste or smell
Congestion or runny nose
*State Requisition Form. Please ignore the (please use comma to separate values) note above, this is only applicable for the State eTOR file.
Date of Onset Today M-D-Y *State Requisition Form. Date of symptom onset.
Patients with underlying medical conditions? Yes No
*State Requisition Form
If Yes, specify: *State Requisition Form
SITE INFORMATION ONLY Is this appointment* must provide value
Walk-in Appointment was scheduled
______ ______ 's age in years View equation
Seasonal and migrant agricultural worker Employee of lodging facilities Employee of businesses who have direct, daily contact with members of the public Visitor from states with a COVID-19 prevalence higher than that in Maine, people participating in large gatherings Other individual who may be at increased risk of COVID-19 based on the duration and density of their recent, potential exposures
*Not included on State form.
Site note for ______ ______
Not included on the State eTOR CSV/Excel File.
Form status dropdown menu below Incomplete ______ ______ . Circle appears red on the Record Status Dashbaord. If selected, this form's data will not be included in the Upcoming scheduled appointments list or the State eTOR CSV/Excel File export.
Complete Appointment was scheduled and specimen has been collected for ______ ______ and will be included on the Upcoming scheduled appointments list and the State eTOR CSV/Excel File export. Appears green on the Record Status Dashboard.
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