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COVID-19 EREQ
Patient Information


Insurance Type


Provider Information


COVID-19 Tests  Select the order code(s) for this requisition

Virus Detection:

720100 - SARS-CoV-2
721010 - Respiratory Panel
720015 - SARS-CoV-2 + Influenza A and B (COVFLU19)
720020 - SARS-CoV-2 (SALIVA)

Virus Antibody:

424455 - SARS-CoV-2 IgG (Spike), Semi-Quantitative
423046 - SARS-CoV-2 IgM

DX Codes:

R05.9 - Cough
R05.1 - Acute cough
R06.02 - Shortness of breath
R50.9 - Fever, unspecified
Z03.818 - Possible exposure
Z11.52 - Encounter for screening for COVID-19
Z20.822 - Contact with and (suspected) exposure to COVID-19


Custom State Required Questions
According to the CDC:
People with COVID-19 have had a wide range of symptoms reported - ranging from mild symptoms to severe illness. Symptoms may appear 2-14 days after exposure to the virus. People with these symptoms may have COVID-19:
  • Fever or chills
  • Cough
  • Shortness of breath or difficulty breathing
  • Fatigue
  • Muscle or body aches
  • Headache
  • New loss of taste or smell
  • Sore throat
  • Congestion or runny nose
  • Nausea or vomiting
  • Diarrhea

General Consent for COVID-19 Testing in the state of Colorado

By submitting this form, I attest that:
  • I authorize this COVID-19 testing unit to conduct collection and testing for COVID-19 through anterior nares or saliva swabs, as authorized by a medical provider or public health official.
  • I authorize my test results to be disclosed to the county, state, or to any other governmental entity as may be required by law.
  • I understand that I am not creating a patient relationship with the testing location by participating in testing. I understand that Mako is not acting as my medical provider. Testing does not replace treatment by my medical provider. I assume complete and full responsibility to take appropriate action with regards to my test results. I agree I will seek medical advice, care, and treatment from my medical provider if I have questions or concerns, or if my condition worsens.
  • I understand that, as with any medical test, there is the potential for a false positive or false negative COVID-19 test result.
  • I have been informed about the test purpose, procedures, possible benefits, and risks. I have been given the opportunity to ask questions before I sign, and I may ask additional questions at any time.
  • My consent for this screening test for COVID-19 is knowing and voluntary.

Allow us to text you when results are ready

You agree that Mako may send automated messages to the phone number you provided above. Messages may include limited health information that will not be encrypted, which you understand may pose some security risk. We do not charge for these notifications, but your carrier’s message and data rates may apply. Participation is not required in order to receive services.