COVID-19 Testing documents

Date *

Full name's patient *

I'am : *

Patient

Patient's guardian

Name (Authorized / Legal Guardian)

Someone charged with the authority of the patient means the rightful representative of a patient less than 20 years old unless they have a marriage certificate. The Legal Guardian has been assigned by court order.

Relationship with patient as

Identity document

National ID card

Driving license

Other card, Specific Other card, Specific

Upload Identity document

Maximum upload size: 268.44MB

Address

as Identity document

Other specificOther specific

Do patient experiencing the following respiratory conditions with Signs and Symptoms *

Patient's PROVINCE current address *

Patient's DISTRICT current address *

History during 14 days before screening *

No risk of covid-19 infections

Departure to/from or stay at pandemic COVID-19 high risk areas ***List of Countries you visited before arriving in Thailand + DateDeparture to/from or stay at pandemic COVID-19 high risk areas ***List of Countries you visited before arriving in Thailand + Date

Work to any authorized ASQ practitioner ***locationWork to any authorized ASQ practitioner ***location

Work with tourist , crowded areas or contact with many people ***job occupation + locationWork with tourist , crowded areas or contact with many people ***job occupation + location

Closed contact with confirmed corona virus 2019 patients or confirmed case's secretion *** relationship with confirmed case's Covid-19 patientClosed contact with confirmed corona virus 2019 patients or confirmed case's secretion *** relationship with confirmed case's Covid-19 patient

Stayed/visited in communities or areas with many people such as ( department store, hospital, public transport, Gambling den, Karaoke room, Pub, Boxing stadium) where found case COVID19 confirmed within 1 month. ***locationStayed/visited in communities or areas with many people such as ( department store, hospital, public transport, Gambling den, Karaoke room, Pub, Boxing stadium) where found case COVID19 confirmed within 1 month. ***location

All information's given and stated above is reliable and true.

Covid-19 instructions

Patient Under Investigation PUI