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  • Chughtai Lab COVID-19 Test Patient Detail (sample form/样表)

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    Ayesha Mehmood
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    The document is a sample COVID-19 test registration form for a patient named Zhan San traveling on flight CA946. It requests information such as name, age, gender, phone number, CNIC/passport number, home address, email, home district in Karachi, how they were referred for testing, reason for the test being international travel, and whether it is a new case or repeat test.

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    W020200630627842911975

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    The document is a sample COVID-19 test registration form for a patient named Zhan San traveling on flight CA946. It requests information such as name, age, gender, phone number, CNIC/passport number, home address, email, home district in Karachi, how they were referred for testing, reason for the test being international travel, and whether it is a new case or repeat test.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
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    127 views1 page

    Chughtai Lab COVID-19 Test Patient Detail (sample form/样表)

    Uploaded by

    Ayesha Mehmood
    The document is a sample COVID-19 test registration form for a patient named Zhan San traveling on flight CA946. It requests information such as name, age, gender, phone number, CNIC/passport number, home address, email, home district in Karachi, how they were referred for testing, reason for the test being international travel, and whether it is a new case or repeat test.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
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    Chughtai Lab COVID-19 Test Patient Detail (sample form/样表)

    Case#:_______________ Date(日期): 　　　　　　


    Name:(姓名) Zhan San (CA946)
    [注：须在姓名后加注所搭乘航班的航班号，否则无法登机/Must add your Flight NO. following
    your Name]
    Father's Name:（父亲姓名）

    Age: （年龄）

    Gender: （性别）

    Phone Number: （巴基斯坦手机号码） [用于接收检测报告短信/receive test report SMS]

    CNIC #: （护照号码）【须准确填写本人护照号码/Must accurately fill in passport No.】


    Home Address Complete:（家庭住址）

    email: abcd**@qq.com【如无巴基斯坦手机，须提供邮箱，用于接收检测报告/If YOU DONOT have


    a local mobile phone, Must provide an email to receive the test report】
    Karachi Home District: Select One Option Mark
    Central (Gulberg, Liaqatabad, New Karachi, North, Nazimabad)
    East (East, Gulshan-E-Iqbal, Jamshed)
    Korangi (Korangi, Shah Faisal Town)
    Malir (Bin Qasim, Landhi, Malir)
    South (Clifton, DHA, Lyari, Saddar)
    West (Baldia, Gadap, Kemari, Orangi, Site, Surjani)

    RFERRED_BY Select One Option

    Personal Hospital Clinic Doctor

    REASON_FOR_TEST Select One Option　　

    Personal Case Contact Suspect Local Travel International Travel√

    Case Status: Select One Option

    New Repeat

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