Заповніть Анкету-направлення для дослідження на COVID-19 онлайн.

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QUESTIONNAIRE-REQUISITION FORM

VISIT UKRAINE PROJECT

For a person who meets criteria for COVID-19 testing

All fields marked "*" are required.

PATIENT’S INFORMATION

Address of living

Place of work, study, children’s institution

Enter the full name of the place of work, school, child care

Examination data

Clinical data

Іf you have crossed the state border of Ukraine, mark “Yes” next to the column “Stay in countries with local Covid-19 virus transmission”, enter the name of the country and enter the date of return / crossing the border in order to transfer this information to ELISS of the Center of Public Health of the Ministry of Health of Ukraine “Diy vdoma” (“Act at home”).

INFORMATION ABOUT HEALTHCARE INSTITUTION AND PHYSICIAN

Order
Cost, UAH
Providing a pre-analytical stage
0
Total
0
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