JSS MEDICAL LAB (M) SDN BHD (748372-D)

25-53, Jalan Bulan BL U5/BL, Bandar Pinggiran Subang,

40150 Shah Alam, Selangor.
Tel: +603-78422677; E-Mail: jss_medicallab@yahoo.com

SARs-nCoV-2 (COVID 19) TEST REQUISITION FORM

Note: All information must be completed below. Patient Sticker is acceptable

PATIENT INFORMATION
Full Name :
NRIC / Passport Number : D.O.B :
Gender : Male Female Ethic : Malay Chinese Indian
Other ________________
Tel : E-mail :
Address

CLINICAL HISTORY
Do you have any symptom(S)? : Fever Cough Sore throat None Others (Specify):
Date of symptom onset : Temperature :

TRAVEL & EXPOSURE HISTORY

Have you travelled outside of Malaysia in the past 4 weeks? : No Yes, I went to
Date of travel : Date of Return :

Have you had close contact with any confirmed case in the past 4 weeks? : No Yes Unknown
Have you attended any gathering in the past 4 weeks? : No Yes Unknown
Exposure Detail :

SPECIMEN INFORMATION
Date of Sampling : Time :
Nasopharyngeal & Oropharyngeal Swab

PIC’s/PATIENT’S SIGNATURE &/OR ORDERING PARTY Lab No.:

STAMP CHOP & DATE
(Signature verifies the identity of the sample(s))

Specimen Received Time:

To be filled by lab personnel