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Covid -19 Booth Copy


ICMR Specimen Referral Form for COVID-19 (SARS-CoV2)


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

SECTION A – PATIENT DETAILS
A.1 TEST INITIATION DETAILS

  • *Repeat Sample:
  • If Yes, Patient ID:

A.2 PERSONAL DETAILS

  • *Patient Name:
  • *Gender:
  • *Mobile Number:
  • *Present patient address:
  • Nationality:
  • *Pincode:
  • Covid-19 Vaccination Status:
    (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
Specimen type :

SECTION B- MEDICAL INFORMATION

B.1 CLINICAL SYMPTOMS AND SIGNS

  • Symptoms Yes
    Cough
    Breathlessness
    Sore throat
  • Symptoms Yes
    Diarrhoea
    Nausea
    Chest pain
  • Symptoms Yes
    Vomiting
    Haemoptysis
    Nasal discharge
  • Symptoms Yes
    Fever at evaluation
    Body ache
    Sputum
  • Symptoms Yes
    Abdominal pain

B.2 REFERRING DOCTOR DETAILS

  • Name of Doctor :
  • Doctor Mobile No.:
  • Doctor Prescription
  • *Aadhaar Card (Front Side)
  • *Aadhaar Card (Back Side)
  • Passport (Front Side)
  • Passport (Back Side)
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