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SAMPLE ID: 14387058 ICMR Specimen Refers Formfor COVID-19 (SARS-Ci 2) This forays foe collection centres abst ‘ io ‘entre! labs to cote details ofthe samples being est fr Cav. 1s soanatry (ol this form for each an every sup ing tate Ii easetil that th colton eeaees Tabs exercise caution to eau thal corset nirmaton sx captured i he lars © arn te | © Seek guidance om requirements forte eel npn © ‘his form maybe lcd an hare wih the Wa © retake wih nteriak ane mandturs SECTION A - PATIENT DETAILS. AW TEST INITIATION DEAMS ‘Aa PERSONAL DETAILS es, Patient 1 sagesQ\earmow FU ager tk “Present Village oF Town: RAYALAMZ “ SPisteorPrecet Healdice MEST GOOANAR! “Gender: Male emale others sat of revert Residence AnvsBageat “aot uber Beccsaatas

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