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This form is for collection centres/ labs to enter details of the samples being tested for Covid-19. It is mandatory to fill this form for each and every sample being tested. It is essential that the collection centres/ labs exercise caution to ensure that correct information is captured in the form. Fields marked with asterisk (*) are mandatory to be filled.

PERSONAL DETAILS

* Patient Name:

* Date Of Birth:

* BCMCH UHID

* Gender

* Patient in quarantine facility

* Panchayath / Municipality / Corporation

* Mobile No

* Mobile Number belongs to:

* District & State of Present Residence:

* Present Address

* Pin Code

Permanent Address(*only for interdistrict/interstate/international travellers):

* Nationality:

Aadhar No. (For Indians):

Passport No.( For Foreign Nationals)

* Downloaded Aarogya SetuApp

TEST INITIATION DETAILS

Type of Test:

Type of Sample:

SPECIMEN INFORMATION FROM REFERRING AGENCY

* Specimentype:

* Collection date and time:

* Sample ID (Label):

PATIENT CATEGORY (PLEASE SELECT ONLY ONE)

CLINICAL SYMPTOMS AND SIGNS

* Symptoms :

PRE-EXISTING MEDICAL CONDITIONS

* Condition :

Chronic lung disease

Malignancy

Heart disease

Chronic liver disease

Chronic renal disease

Diabetes

Hypertension

Immunocompromised condition:

Yes No

Other underlying conditions:

HOSPITALIZATION DETAILS

* Hospitalized :

Hospital Name :

Hospital ID/number :

Hospitalization Date :

Hospital State :

Hospital District :

REFERRING DOCTOR DETAILS

Name of Doctor :

Doctor Mobile No :

Doctor Email ID :

ICMR Specimen Referral Form for COVID-19 (18-09-2020)- Kerala