Patient Information Form
In order to facilitate a fast and safer service for your PCR appointment, we would like to request for you to accomplish this patient information form. Please be reminded that all information submitted through this form will be kept secure and confidential and will only be used for the conduct of the laboratory test. If you have other concerns, you may contact us at 0917-886-4663 or send us an email at concierge@labathomeph.com
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Email *
Patient Name (Surname, First Name, Middle Name) *
Birthdate (MM-DD-YYYY) *
MM
/
DD
/
YYYY
Age *
Gender *
Civil Status *
Nationality *
Mobile Number *
Email Address (for results) *
Home Address *
Occupation:
Works in a Closed Setting? *
Have previous COVID-related consultation with a physician? *
Vaccination Status (Example: 1st - Pfizer,  2nd - Pfizer)
Vaccination Dates: (Example: Aug 15, 2021; Sept 16, 2021) Please indicate 2 dates for patients with 2nd dose
Experiencing COVID-related symptoms? *
If yes, when is the onset of the symptoms/illness:
MM
/
DD
/
YYYY
Please specify experienced symptoms, if any:
Please type if any of these co-morbidities applies to the patient (type N/A - if not applicable)
Captionless Image
Purpose for Testing *
If for travel purposes, please specify your Passport Number
If for travel purposes, please state the date and time of your flight (Ex: Dec 2, 2021, 17:00 PST)
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