• TEST REQUISITION FORM FOR SARS-CoV-2 ANTIGEN TEST

  • SECTION A - PATIENTS DETAILS

    A.1 PERSONAL DETAILS
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  • A.2 SPECIMEN INFORMATION

  • SECTION B- MEDICAL INFORMATION

    B.1 CLINICAL SYMPTOMS AND SIGNS

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    Pick a Date

  • B.3 HOSPITALIZATION DETAILS

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    Pick a Date
  • B.4 REFERRING DOCTOR DETAILS

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  • Note: As per ICMR guideline if I am Symptomatic and found Negative, I have to do confirmaiton with RT-PCR test. I will follow the protocol of ICMR.
  • Clear
  • TEST RESULT (To be filled by Covid-19 testing lab facility)

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    Pick a Date
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    Pick a Date
  • Clear
  • Should be Empty:
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