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RT-PCR (Special Online Promo RM250)
RTK-Antigen (Special Online Promo RM180)

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Integral Occupational Health Services Sdn. Bhd. (Integral OHS) [MAP]
Lot 2-05, Level 2, Menara HLA, No.3, Jalan Kia Peng, 50450 KL.
03- 21712882

Klinik Nur Syifa [MAP]
No 77 Jalan 8/1 seksyen 8 , Bandar Baru Bangi 43650 Selangor.
03-89222300

Klinik Hasilcare [MAP]
Unit 1, Aras Bawah, Blok 11, Kompleks Kerajaan Cawangan Duta, Jalan Tuanku Abdul Halim, 50480, KL
03-62114666

Registration and Test Request Form

Name NRIC / Passport DOB Age

Gender Male Female

Reference Address Contact Number Email Address

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.