Report No.

P_2021_04_08_021882
06 25
06 26
dated 2021-04-09
2021-06-26
2021-06-26
2021-06-26
Molecular test for SARS-CoV-2 on a sample taken from a nasopharyngeal
swab
using the RT-qPCR method

Name and address of Łukasiewicz Research Network

performing entity PORT Polish Center for Technology Development
Healthcare-Med Medical Diagnostic Laboratory
Stabłowicka 147, 54-066 Wrocław

Ordering entity / information on the collection of results

Patient / dawidowska_p@wp.pl

Patient's details*
Surname and first name of the patient or
patient identification number, where other DOMINIK
PAULINA SIKORA
DAWIDOWSKA Sex: F
M
details are unavailable:

PESEL [National Identification

Number] and number of an 98042307205/EH8072271
02210501090/CAD629958 Date of birth: 1998-04-23
2002-01-05
identity document:

Patient’s address: 45-109 OPOLE

48-300 NYSA KORNECKIEGO 45
SŁOWIAŃSKA 21/26

Sample description*
Details of a person collecting the sample IZA PYRCZ
Sample collection date / sample collection
2021-04-08
2021-06-25 10:15
time

Date/time the sample is received for testing 2021-04-08

2021-06-25 12:30

Remarks: 0

Test
Test commencement date 2021-04-08
2021-06-25
Test completion date 2021-06-26
2021-04-09
Equipment used QuantStudio 6 Pro
Isolation kit NucleoMag Dx Pathogen
Detection kit MACCURA SARS CoV-2 Fluorescent PCR 2019-nCoV

Test result for SARS-CoV-2:

Negative

Comments Genetic material of SARS-CoV-2 virus was not detected

Additional notes:
* details provided by the client; the laboratory does not bear liability for any information provided by the client which could affect the validity of
the result.

The result refers only to the provided sample. The client is entitled to file a complaint related to the way the order has been delivered. The
complaint procedure is available at the Healthcare-Med. Medical Diagnostic Laboratory. Any reports with test results may only be copied in full.
Test samples collected by Medical Diagnostic Laboratory Healthcare-Med. staff, employees of external companies and samples delivered by the
ordering entity are handled in line with the Instructions for the collection and transport of materials for microbiological tests, available at
Medical Diagnostic Laboratory Healthcare-Med. No extraordinary circumstances, which might affect the validity of results, occurred during the
performance of the test. Medical Diagnostic Laboratory Healthcare-Med. accepts a standard use of its test results in treatment and health
prevention, and for own purposes of the ordering entity and/or the patient. The issues related to compliance with the
requirements/specifications and the risk of wrongful acceptance/ rejection were laid down in the Instructions for the collection and transport of
materials for microbiological tests available at Medical Diagnostic Laboratory Healthcare-Med. Information on personal data processing required
under Regulation (EU) 2016/679 of the European Parliament and of the Council, referred to as GDPR, has been attached to this report.

Authorizing the test result:

Magdalena Kaczmarek Nr PWZDL 08618 06 26
2021-04-09
2021-06-26

First name and surname Date / Signature

*The document validated by qualified electronic signature

END OF TEST REPORT
Healthcare-Med-PO-06-Z-02 edycja 1 z dnia 04.01.2021