• Fields marked with asterisk (*) are mandatory to be filled

• *Repeat Sample: YES NO
• If Yes, Patient ID:

• *Patient Name:
• *DOB:
• *Gender: Male Female Other
• *Mobile Number:
• *Present patient address:
• Nationality:
• *Pincode:
• Covid-19 Vaccination Status: Yes No

  (These fields to be filled for all patients including foreigners)

• *Email:
• Passport No. :
• * Aadhar No.(For indians) :
  
• Father Name/ Husband Name (As
  mentioned in aadhar Card

• Collection Date :
• Sample Collection By :
• Sample ID (Label):
• Sample Collector’s Phone No. :