A request form for self-sampling
Your personal information
Registration is completed
{{ kitCode.feedback }}
{{ kitCode.feedback }}
{{ registration.firstName.feedback }}
{{ registration.firstName.feedback }}
{{ registration.lastName.feedback }}
{{ registration.lastName.feedback }}
{{ registration.nationality.feedback }}
{{ registration.nationality.feedback }}
{{ registration.insurance.feedback }}
{{ registration.insurance.feedback }}
{{ registration.insuranceId.feedback }}
{{ registration.insuranceId.feedback }}
For foreigners without an insurance number, fill in the date of birth in the day/month/year format.
{{ registration.sampleDate.feedback }}
{{ registration.sampleDate.feedback }}
{{ registration.phoneNumber.feedback }}
{{ registration.phoneNumber.feedback }}
{{ registration.email.feedback }}
{{ registration.email.feedback }}
Adress of your residence
{{ registration.street.feedback }}
{{ registration.street.feedback }}
{{ registration.city.feedback }}
{{ registration.city.feedback }}
{{ registration.postalCode.feedback }}
{{ registration.postalCode.feedback }}
Did you have symptoms?
{{ registration.hasSymptoms.feedback }}
{{ registration.hasSymptoms.feedback }}
{{ registration.firstSymptomsDate.feedback }}
{{ registration.firstSymptomsDate.feedback }}
If so, specify:
{{ registration.symptoms.feedback }}
{{ registration.symptoms.feedback }}
{{ registration.symptomsOther.feedback }}
{{ registration.symptomsOther.feedback }}
{{ registration.confirmed.feedback }}
{{ registration.confirmed.feedback }}