Covid-19 Antigen Test Registration

Name *

Address *

Email Address *

Phone *

Date of Birth *

Age *

Sex *

ID Type: *

ID No. *

ID Expiry Date *

Reason for Testing *

Symptomatic Travel Option-Contact with someone who tested positive Other

If other

Symptomatic *

Yes No

Date of Symptom Onset

How would you like to receive the test results? * *

Have you been hospitalized? * *

Yes No

ICU *

Yes No

Any Symptoms? Choose all that apply *

Dry cough Fever Lost of smell or taste Shortness of breath Diarrhoea Nausea/Vomiting Headache Muscle/Body Aches Asymptomatic

Has the patient had direct contact with someone who has tested positive for COVID-19? *

Yes No

Has the patient had a recent travel history within last 2 weeks? *

Yes No

Pregnant *

Yes No

Please carefully read the following informed consent:

I authorize this COVID-19 testing unit to conduct collection and testing for COVID-19 through a nasopharyngeal swab, as ordered by an authorized medical provider or public health official.
I authorize my test results to be disclosed to the MOHW as may be required by law.
I acknowledge that a positive test result is an indication that I must self-isolate in an effort to avoid affecting others.
I understand that, as with any medical test, there is the potential for false positive or false negative test results.
I understand that testing does not replace treatment by my medical provider nor is the testing unit acting as my medical provider. I assume complete and full responsibility to take appropriate action with regards to my test results.
I, the undersigned, have been informed about the test purpose, procedures, possible benefits and risks. I have been given opportunity to ask questions before I sign. I voluntarily agree to testing for COVID-19.

I accept the above terms. *

I have read and accept all the terms above

Today's Date *