Specimen Registration
Specimen Number
xx-yymm-xxxxxx
Collect Specimen Date
DD-MM-YYYY
Specimen Type
Deep Throat Saliva
Referring Doctor
Chan Tai Man
Personal Detail
Surname
Surname
First Name
Frist Name
Chinese Surname
Surname
Chinese First Name
Frist Name
Gender
M
Date of Birth
DD-MM-YYYY
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 currently experiencing, or have you experienced a fever within the past 14 days?
No
2. In the past 14 days, have you travelled outside of Hong Kong?
No
Travel Location
Hong Kong
Travelling Period
2020/09/10 - 2020/09/15
3. Is your occupation healthcare or medical related?
No
4. In the past 14 days, have you been in close proximity with any cluster diagnosed with having COVID-19?
No
5. In the past 14 days, have you been in close proximity with anyone diagnosed with having COVID-19?
No
6. Are you travelling to Mainland China or Macau?
No