COVID-19 Drive Thru Test Registration

Car Plate (If walk in please insert NA)*

Payment Method *

Payment Reference

Home Address (Insert full address for Ministry of Health notification)*

Address 3

State

Postcode *

Did patient have FEVER (>37.5°C)? *

Yes

No

Did patient have COUGH? *

Yes

No

Did patient have SORE THROAT? *

Yes

No

Did patient have difficulty in breathing? *

Yes

No

Did patient have body weakness? *

Yes

No

Did patient have diarrhea? *

Yes

No

Did patient have close contact with confirmed COVID-19 patient? *

Yes

No

COVID-19 Drive Thru Test Registration

Full Name as per IC/ PASSPORT *

Identity Type *

Identity Number **

Identity Number **

Nationality

Date of birth *

Gender *

Phone Number (Please insert valid phone number)*

Email *

Car Plate (If walk in please insert NA)*

Payment Method *

Payment Reference

Home Address (Insert full address for Ministry of Health notification)*

Address 3

State

Postcode *

Did patient have FEVER (>37.5°C)? *

Did patient have COUGH? *

Did patient have SORE THROAT? *

Did patient have difficulty in breathing? *

Did patient have body weakness? *

Did patient have diarrhea? *

Did patient have close contact with confirmed COVID-19 patient? *