COVID-19 Drive Thru Test Registration

Full Name as per IC/ PASSPORT *
Identity Type *
Identity Number **
** Ensure it is correct, no changes after submission
Identity Number **
** Ensure it is correct, no changes after submission
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)*
State
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? *