Electronic application form | covidlab.cz

A request form for self-sampling

Your personal information

Registration is completed

Name:

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Surname:

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Nationality:

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Health insurance/self-paying pacient:

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Insurance number/personal identification number:

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For foreigners without an insurance number, fill in the date of birth in the day/month/year format.

Date of sampling:

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Contact phone number/cell phone number:

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E-mail:

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Adress of your residence

Street and house number:

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City:

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Postal code:

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Note to symptoms:

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I declare that there is a sample of the person being tested in the test tube.

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Thank you for the registration, thus saving time for the staff of sampling sites and laboratories.