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Registrationmpendulo2021-03-05T06:53:10+00:00

Registration Form

Patient Details

Patient ID Number *
Patient Surname *
Patient Initials And First Name *
Patient Date of Birth*
Gender MaleFemale
Age *
Passport Number
Contact Number(cell)
Email Address
Hospital Patient YesNoFastingRandom
Collection Date
Time:

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.
YesNo

SARS-Cov-2 (COVID-19) Request

Test:

C290PCR SARS-Cov-2
Sample Types SputumNasal SwabNasopharyngeal SwabTracheal AspirateThroat SwabBroncho Alveolar Lavage
Indication Contact with a known positive casePre-Admississions or PreSurgeryHealthcare workerTravellingOther
Patient Physical Address
Code

Clinical Presentation

Date of onset of symptoms
Symptoms (Tick all that apply)Fever(>38 Degree Celcius)CoughChillsSore ThroatShortness of breathNausea/VomitingDiarrhoeaNoneOther
Specify

Schedule Swabbing

Date of swabbing
Preferred Time (Weekday) Or
Time (Weekend)

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

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