Request an Appointment
FAQ
Patient Survey
CIF – COVID 19 (2019-nCoV)
Emergency Line
(+233) 050 293 9712
|
WhatsApp
+233 24 258 9802
×
Home
Our Clinic
About Us
Our Staff
Careers
Services
Client
Corporate Registration Form
Family Registration Form
Foreigners/Tourists
Resources
Blog
Contact
MENU
CASE INVESTIGATIONS FORM – COVID 19 (2019-nCoV)
CASE INVESTIGATIONS FORM - COVID 19 (2019-nCoV)
Personal Information
You are important to us. Please help us serve you better by taking a few minutes to express your satisfaction on our services rendered to you today.
Name
*
Name
First
First
Last
Last
Address:
*
Date
*
Date of Birth
*
Age
*
If Child is greater than one year, state number of months
If Child is less than a month, state in days
Sex
*
Male
Female
Phone
*
Email
Patient symptoms
(check all reported symptoms)
*
History of fever/chills
General weakness
Cough
Runny nose
Shortness of breath
Headache
Sore throat
Other
Other
Reason for Testing
Let us know why you want to take the test
*
Having Symptoms
Had Contact With a COVID Patient
Having Employment
On Request of My Employer
Test After Treatment
Runny Nose
Other
Other
Sampling Type:
How will your sample be taken
*
Nasopharyngeal Swab
If you are human, leave this field blank.
Submit
Copyright ©2020 all rights reserved
Designed by
Gehmatec Solutions
