Рус

7:00 - 20:00

Горячая линия для клиентов

0 800 217 887

Консультация врача для клиентов

0 800 219 696

Горячая линия для врачей

0 800 752 180

Горячая линия для клиентов

0 800 217 887

7:00 - 20:00

Консультация врача для клиентов

0 800 219 696

7:00 - 20:00

Горячая линия для врачей

0 800 752 180

7:00 - 20:00

Многоканальный телефон для жителей города Киев

Корзина

Фундация ДІЛА

Мы задаем стандарты качества и содействуем развитию культуры лабораторной диагностики в Украине во имя здоровья каждого человека

Реєструйтесь на професійні заходи для лікарів та отримуйте сертифікати з балами БПР

Мы обеспечиваем медицинским центрам и страховым компаниям возможность использовать в своей практике уникальный лабораторный продукт высокого качества

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QUESTIONNAIRE-REQUISITION FORM

QUESTIONNAIRE-REQUISITION FORM¹

For a person who meets criteria for COVID-19 testing

All fields marked with "*" are mandatory to fill

Full name - be sure to indicate in the language indicated in the identity documents (English / Ukrainian / Latin).

SURVEY DATA

Need the guaranteed result in 8 hours in Kyiv or in 24 (36) hours in the regions?

Choose - Coronavirus (SARS-Cov-2), COVID-19, RNA by RT-PCR-qualitative, FTD (urgent)

LABORATORY TESTS

Request urgent PCR examination

Departure of the nurse home

Examination in the department DILA

Locality

Wet seal

Giving conclusion in English

Passport series

Passport number

Department DILA

Show on map

Enter the street name for quick browsing

	Address	Taking biomaterial (by PCR)	Show on map

PATIENT’S INFORMATION

Last name

First name

Patronymic name

Date of birth

Age (y.o.)

Representative last name

Representative first name

Representative middle name

Gender

Contact telephone / or registered in the "Act_at_Home" Program

E-mail

Home address in Ukraine

Country

Region

Locality

District

Street.

Building №

Appartment №

Lives

Clinical data

If you crossed the state border of Ukraine, select YES mark next to the column "Stay in countries with local transmission Covid-19", choose your country and enter return date / border crossing to transfer information in Ministry of Health of Ukraine for "Action at Home".

Reason for testing

Have you been staying in the countries with local SARS-CoV-2 transmission?

Yes

Country

Date of return

Have you had a contact with a laboratory confirmed Covid-19 patient?

Yes

Unknown

Additional comments

Замовлення

Order

Quantity, pcs

Price, UAH

Providing pre-analytical stage

Giving conclusion in English

Giving conclusion in English PCR COVID

Home visit from the nurse

Total

Group order

Quantity, pcs

Price, UAH

Total price, UAH

Providing pre-analytical stage

Giving conclusion in English

Giving conclusion in English PCR COVID

Home visit from the nurse (for group)

Total

¹According to the Executive Order of the Ministry of Health of Ukraine #722 from the 22nd of March 2020 in case of positive COVID-19 test result the Medical Laboratory is obliged to immediately inform the person’s Primary Healthcare Provider for the further case registration and sending the form #058/o to the laboratory center of the Ministry of Health of Ukraine. The form #058/o/ contains personal data including place of work/study, address, age etc., thus this data is mandatory to be filled in this Questionnaire.

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QUESTIONNAIRE-REQUISITION FORM1

SURVEY DATA

PATIENT’S INFORMATION

Home address in Ukraine

Clinical data

QUESTIONNAIRE-REQUISITION FORM¹