Test

PCR TEST QUESTIONNAIRE
CORONAVIRUS DISEASE 2019

Please fil in the Feilds of the form, answer the questions, sign & press Submit Button.
You will receive the results in your E-mail, within 24-36 hours.

Full Name*

Contact No*

Passport No*

Country of Origin*

Date of Birth*

Date of Examination*

Time of Examination*

1). Do you have fever (>37°C) or I and cough or/and dyspnea today or the past 14 days?

No Yes

2). Have you been in contact with a person who had fever or had been in 14 days mandatory quarantine ?

No Yes

3). Are you / or have been in 14 days mandatory quarantine ?

No Yes

4). Have you been hospitalized or visited another hospital or diagnostic center in the past 14 days ?

No Yes

5). Do you have muscle pain, headache, sore throat, runny noise, diarrhea, nausea, vomiting, anosmia?

No Yes

SYMPTOMS

If yes, please describe here.

6). Do you take anipyretics or painkillers?

No Yes

7). Do you accept to have the SARS-COV 2 real time PCR test performed ?

No Yes

8). Have you been vaccinated for Coronavirus disease (COVID-19)?

No Yes

Please Read & Check*

On my own responsibility I hereby declare that all the information given above is true to the best of my knowledge and beliet

Please Sign Here

WE STRONGLY RECOMMEND TO RE-PERFORM THE TEST IN 7 DAYS

*We inform you that by law we are forced to announce Isubmit your test results to the following Greek Health Authorities: Cyclades Medical Association & EODY.GOV.GR - National Public Health Organization