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Registration for COVID Test
*
Fields marked with asterisk are mandatory to be filled
Patient Name:
Present Patient address:
District, State
Pincode:
Date of Birth (DD/MM/YYYY):
DD
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MM
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2020
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Gender:
Male
Female
Other
Email Id:
Mobile No:
Appointment Request Date (DD/MM/YYYY):
Day
01
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Month
09
10
11
12
2020
Preferred Time Slot
Please Select
08:00AM to 09:00AM
09:00AM to 10:00AM
10:00AM to 11:00AM
11:00AM to 12:00PM
12:00PM to 01:00PM
01:00PM to 02:00PM
02:00PM to 03:00PM
03:00PM to 04:00PM
04:00PM to 05:00PM
05:00PM to 06:00PM
06:00PM to 06:30PM
Nationality
Aadhar No. (For Indians)
Passport No. (For Foreign Nationals)
* Aadhar Card Photocopy Mandatory
Upload Aadhar Front Side where your photo is visible
Incase you do not have Aadhar card you can upload your driving licence or passport or election card front and back photo copy
Upload Aadhar Back Side where address is visible
PLEASE SELECT ONLY ONE
Cat 1: Symptomatic international traveller in last 14 days
Cat 2: Symptomatic contact of lab confirmed case
Cat 3: Symptomatic Healthcare worker / Frontline workers
Cat 4: Hospitalized SARI (Severe Acute Respiratory Illness) patient
Cat 5a: Asymptomatic direct and high risk contact of lab confirmed case - family member
Cat 5b: Asymptomatic healthcare worker in contact with confirmed case without adequate protection
Cat 6: Symptomatic Influenza like Illness (ILI) in Hospital
Cat 7: Pregnant woman in / near labour
Cat 8: Symptomatic (ILI) amongh returnees and migrants (within 7 days of illness)
Cat 9: Symptomatic Influenza Like Illness(ILI) patient in Hotspot / Containment zones
Other: (please specify) * (Select “other" only if the patient doesn’t belong to category 1-8)
SECTION B- MEDICAL INFORMATION
B.1 CLINICAL SYMPTOMS AND SIGNS
Symptoms
Yes
No
Symptoms
Cough
Diarrhoea
Vomiting
Fever at evaluation
Abdominal pain
Breathlessness
Nausea
Haemoptysis
Body ache
Sore throat
Chest pain
Nasal discharge
Sputum
Which of the above mentioned was First Symptom:
None
Cough
Diarrhoea
Vomiting
Fever at evaluation
Abdominal pain
Breathlessness
Nausea
Haemoptysis
Body ache
Sore throat
Chest pain
Nasal discharge
Sputum
Date of onset of First Symptom:
B.2 PRE-EXISTING MEDICAL CONDITIONS
Condition
Chronic lung disease
Malignancy
Heart disease
Chronic liver disease
Chronic renal disease
Diabetes
Hypertension
Immunocompromised condition:
Yes
No
Other underlying conditions
B.4 REFERRING DOCTOR DETAILS
*
Name of Doctor
Doctor Mobile No.
Doctor Email ID
