TEST REQUISITION FORM FOR SARS-CoV-2 ANTIGEN TEST

Name *

First Name Last Name

Email *

example@example.com

Patient in quarantine facility: *

Yes No

Present Village or Town: *

District of Present Residence: *

State of Present Residence: *

Present Patient address: *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

Age: *

Gender: *

Male Female Other

Nationality: *

Mobile Number: *

Area Code Phone Number

Mobile Number belongs to: *

Self Family

Downloaded Aarogya Setu App: *

Yes No

Aadhar No (For Indians):

Passport No (For Foreign Nationals):

Specimen Type: *

Nasopharyngel Swab

Collection date: *

Sample ID (Label):

A.4 PATIENT CATEGORY (PLEASE SELECT ONE)

SECTION A - PATIENTS DETAILS