Covid19 - Testing

ANTIBODY TESTING

Last name:

First name:

Mobile:

Mode of testing:

Preferred Appointment Date:

Preferred Appointment Time:

Plate number:

Type of test:*

Antigen Testing - PHP 660.00

Rapid Antibody - Php 1,000.00

Roche Eclia - Php 1,500.00

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Middle name:

Email address:

Gender:

Address:

Birthdate:

Company:

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1. Within the past 14 days, I have been exposed to someone who has been sick with fever, cold or flu symptoms or diagnosed with COVID-19. Please choose answer	Yes	No
2. Within the past 14 days:
a. I have been sick with cold or flu Please choose an answer.	Yes	No
b. I have had a fever Please choose an answer.	Yes	No
c. I have had a sore throat Please choose an answer.	Yes	No
d. have had nausea and vomiting Please choose an answer.	Yes	No
e. have had diarrhea Please choose an answer.	Yes	No
f. have had loss of smell and loss of taste Please choose an answer.	Yes	No
g. I have had a dry cough Please choose an answer.	Yes	No
3. I was diagnosed with COVID 19 and am fully recovered. Please choose an answer.	Yes	No

Diagnosis date:

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