Specimen Registration
Specimen Number
xx-yymm-xxxxxx
Specimen Collection Date
YYYY-MM-DD
Specimen Type
Deep Throat Saliva
Referring Doctor
Chan Tai Man
Medical Council Registration No.
xxxxxx
Clinic Reference No.
xxxxxx
Personal Detail
Surname
Surname
First Name
Frist Name
Chinese Surname
Surname
Chinese First Name
Frist Name
Gender
M
Date of Birth
YYYY-MM-DD
ID Document Type 1
HK ID
ID Document No 1
A1234563
ID Document Type 2
HK Passport
ID Document No 2
H1234556789
Country / Region Code
852
Mobile Phone Number
55667788
Email
123456789@gmail.com
Questionnaire
1. Are you under the COMPULSORY TESTING SCHEME FOR TARGET GROUPS?
NB: If YES, you are declaring that your sample was not self collected and your results will be uploaded to the Centre for Health Protection of the Department of Health of the Government of the Hong Kong Special Administrative Region.
No
2. Are you using your report for TRAVELLING PURPOSES?
NB: If YES, you are declaring that your sample was not self collected and your results will be uploaded to the Centre for Health Protection of the Department of Health of the Government of the Hong Kong Special Administrative Region.
No
3. Are you currently experiencing a fever/chill, cough, shortness of breath, difficulty breathing, fatigue, muscle or body aches, loss of taste or smell, sore throat, nausea or vomiting or diarrhea?
No
4. In the past 14 days, have you been in close proximity with anyone who was experiencing any of the above symptoms (Q3) or has experienced any of the above symptoms (Q3) since your contact?
No
5. In the past 14 days, have you been in close proximity with anyone or cluster who has tested positive for COVID-19?
No