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Formulir Pendaftaran Online Screening Covid-19 Klinik Kimia Farma Batam Center
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* Indicates required question
No. NIK/ No. Passport
*
Your answer
Nama/ Name
*
Masukkan nama sesuai KTP (please enter your name according your passport)
Your answer
Tanggal Lahir/ DOB
*
MM
/
DD
/
YYYY
Jenis Kelamin/ Sex
Laki-laki/ Man
Perempuan/ Female
Clear selection
Alamat Domisili/ Address
*
Your answer
No. HP / Phone Number
*
Jika tidak ada isikan tanda "-" (if not available please enter "-" symbol
Your answer
Pemeriksaan
*
Rapid Test Antigen
Rapid Test Antibody
PCR
Tanggal pemeriksaan
*
isikan tanggal pemeriksaan, dan pastikan anda datang sesuai dengan tanggal pemeriksaan tersebut
MM
/
DD
/
YYYY
Demam/Riwayat Demam ≥38 ⁰C dalam 14 hari terakhir (Fever symptoms for the past 14 days)
Ya/ Yes
Tidak/ No
Clear selection
Batuk/Pilek (Cough/Cold)
Ya/ Yes
Tidak/ No
Clear selection
Nyeri Tenggorokan (Sore Throat)
Ya/ Yes
Tidak/ No
Clear selection
Sesak Napas (Heavy to Breath)
Ya/ Yes
Tidak/ No
Clear selection
Pernah melakukan perjalanan keluar negeri /luar kota di Indoensia dalam 14 hari terakhir.(Have traveled to another country or city in Indonesia in the last 14 days)
Ya/ Yes
Tidak/ No
Clear selection
Kalau Ya, sebutkan Nama Negara/ Kota yang anda kunjungi (If Yes, please mention the country/ The City you had visited)
*
ijika Tidak, masukkan tanda "-" (if No, please enter "-" symbol
Your answer
Pernah kontak erat dengan pasien positif Covid-19 dalam 14 hari terakhir.(Had close contact with a positive patient with Covid-19 in the last 14 days)
Ya/ Yes
Tidak/ No
Clear selection
Bekerja di lingkungan yang sudah terpapar Virus Covid-19.(Work in an environment that has been exposed to the Covid-19 Virus)
Ya/ Yes
Tidak/ No
Clear selection
Apakah pernah Rapid Test dengan hasil reaktif ?(Have you ever had a Rapid Test with reactive results?)
Ya/ Yes
Tidak/ No
Clear selection
Apakah pernah Test RT PCR / Swab Test ?Have you ever had the RT PCR / Swab Test?
Ya/ Yes
Tidak/ No
Clear selection
Dengan ini menyatakan data yang saya isi adalah benar dan saya bersedia untuk diambil spesimen untuk pemeriksaan Covid-19. Jika dikemudian hari didapat tidak benar maka melepaskan tanggung jawab Kimia Farma sebagai penyelenggara layanan pemeriksaan Covid-19. Dengan ini saya juga menyatakan bahwa semua informasi yang berhubungan dengan pelayanan ini sudah saya ketahui, termasuk efek sampingnya atau kejadian ikutan pasca pelayanan ini. (Hereby, I declare that the data that I have filled in is truthfull and I am ready to collect specimens for Covid-19 examination. If it is found incorrectly in the future, it will release Kimia Farma's responsibility as the provider of the Covid-19 inspection service. And I declare too that I haveI hereby also declare that I have known all information related to this service, including side effects or post-service side events).
Ya, bersedia/ Yes, I do
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