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How to use or fill out NOVEL INFLUENZA A (H1N1) TEST REQUEST FORM STATE OF UTAH
- Click ‘Get Form’ to open it in the editor.
- Begin by filling out the 'Patient Information' section. Enter the patient's name, ID number, date of birth, age, and sex clearly.
- Next, complete the 'Provider Information' section. Input the provider code, physician's name, phone number, email address, and secure fax number.
- In the 'Specimen' section, indicate the collection date and select the specimen source/site from the provided options.
- For 'Clinical/Epidemiologic Criteria for Testing', ensure you check all applicable criteria that justify testing for Novel Influenza A (H1N1).
- Review all entries for accuracy before submitting. Ensure that every field is filled out completely as testing will not be performed unless this form is fully completed.
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| Versions | Form popularity | Fillable & printable |
|---|---|---|
| 2009 | 4.7 Satisfied (29 Votes) |
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