CoVid-19 Testing Appointment (新冠检测预约)



Last Name(姓):*
First Name(名):*
Gender(性别):*
Date of Birth(出生日期):*
Address(地址):
City(城市):
State(州):
Zip Code(邮政编号):
Phone(电话号码):*
Email(电子邮件地址):*
Passport Type(护照类别):
Passport Number(护照号码):
Citizen of(国籍):*
Reason for test(申请检测的原因):*
Traveling to China (国际旅行去中国)
Air travel (其它旅行)
Referred by Other Physicians (医生转诊: 请带转诊单)
Test requested (您想做以下那些检测):*
COVID-19 PCR Test (新冠核酸PCR)
SARS-COV Antibody IgM (IgM抗体)
SARS-COV Antibody IgG (IgG抗体)
IgM/IgG (Colloid Gold) (N蛋白抗体)
Have you received COVID-19 Vaccine?(您是否打过非灭活疫苗?):*
Yes (是)
No (否)
If you are found IgM Positive, do you agree to further test for N protein antibodies?(如果IgM阳性,您是否同意加做N蛋白抗体检测?):*
Yes (是)
No (否)
Date (预约日期):*
Available Time (预约时间):*
*Required field (必填项目)