DANGS001

ICMR Specimen Referral Form for COVID-19 (SARS-CoV2)

SECTION A – PATIENT DETAILS
A.1 TEST INITIATION DETAILS
(If yes, attach prescription; If No, test cannot be conducted)
A.2 PERSONAL DETAILS




(These fields to be filled for all patients including foreigners)
A.3 SPECIMEN INFORMATION FROM REFERRING AGENCY (Not to be filled by Patient)
A.4 PATIENT CATEGORY (PLEASE SELECT ONLY ONE)










SECTION B- MEDICAL INFORMATION
B.1 CLINICAL SYMPTOMS AND SIGNS
If No please go to B.2 section
B.2 PRE-EXISTING MEDICAL CONDITIONS
B.3 HOSPITALIZATION DETAILS


B.4 REFERRING DOCTOR DETAILS
* Fields marked with asterisk are mandatory to be filled
MANDATORY DOCUMENTS* : (supported file types are .jpg, .jpeg, .png, .pdf, .gif)
Payment Details* (INR 2,400 to be paid for the COVID19 Test)

After your sample is collected, you will receive an SMS with Unique ID & Password for our Website Login and making Online Payments on www.drdangslab.com

Post submission please wait for a call from our team to confirm the exact timing of the collection