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Integral Occupational Health Services Sdn. Bhd. (Integral OHS) [MAP]



Klinik Nur Syifa [MAP]



Klinik Hasilcare [MAP]

Registration and Test Request Form

Gender Male Female


Patient’s Declaration

1. Have you been treated for Covid-19 within the past 3 months?
Yes
No
2. Have you ever travelled to any RED ZONE in recent month?
Yes
No
3. Do you have any of the following symptoms: fever, sore throat, cough, running nose, body ache and body discomfort?
Yes
No
4. Do you have any close contact with anyone who has visited to RED ZONE (relatives/friends) or person with the symptoms listed in Question 3?
Yes
No
5. Have you done any surgery in these past years?
Yes
No
If yes, please indicate:
6. Do you have any history of diabetes/ hypertension/ other disease?
Yes
No
If yes, please indicate:
7. Do you have any allergy?
Yes
No
If yes, please indicate:


I have read or have had explained to me information about Covid-19 testing. I understand the benefits and risks of Covid-19 testing, and it is my choice getting the test. I agree to get the test and consent to this information being given to my healthcare and MOH to update applicable records.