Registration Form

    Patient Details

    Confirmation of information
    I certify that the above information is true and correct, and will be contained within my results report. I understand that any misrepresentation or omission of any information contained above is my responsibility.

    SARS-Cov-2 (COVID-19) Request


    Clinical Presentation
    Schedule Swabbing
    1. Or

    Patient Consent
    Clicking the submit button below indicates my understanding of, and my agreement to comply with the terms of the legal declaration, provide consent for the processing of personal information and the releasing of test results as documented on the back of this form. I give consent for tests and guarantee payment of any amounts. I consent that ICD10 codes may be provided to my medical aid as per statutory requirements on my account.

    * Required