COVID-19 Test Registration Form
(Only for International travellers)

Fields marked * are mandatory!

Travel Destination *

Date of Travel*

Test type *

RTPCR(Rs- 500)Express Testing(Rs- 3000)

Test Date*

Reason for testing *

Complete Name*

Age(Years)*

Gender* MaleFemaleOther

Contact Number*

Email ID*

Hospital Number(Patient Registration Card of KH)

Father's Name *

Address*

Passport Number *

Present symptoms

Date onset of first symptoms

Pre existing medical condition*

Received COVID-19 vaccine* YesNo

Aadhar Number

Have you downloaded Aarogya Setu app* YesNo

Have you come in contact with any lab confirmed COVID-19 patient * YesNo

Any history of travel in last one month* YesNo

History of COVID-19 test previously

Date:

Test report

After successful payment please download the receipt and produce it during the sample collection.