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Covid-19 (RTPCR) Test Appointment Scheduling Form
Please fill in the details mentioned below to help us in scheduling your Covid-19 Test
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* Indicates required question
Email
*
Your email
Name
*
Your answer
Contact No / Mobile No
*
Your answer
Alternate Contact No / Mobile No
*
Your answer
Gender
*
Your answer
Age
*
Your answer
Name of the City where Covid-19 Test has to be scheduled?
*
Your answer
Complete Residential Address (For Home Sample Collection)
*
Your answer
Pin Code
*
Your answer
Landmark
*
Your answer
Preferred Appointment Date (Aptt will be scheduled after 24 hours from the Date of Request)
*
MM
/
DD
/
YYYY
Preferred Appointment Time (Sample will be collected between 8 am to 6 pm Mon to Sat)
*
Time
:
AM
PM
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