Details Submitted

Validation Code:810265
Patient Given Name: Buddy
Patient Middle Name: John
Patient Lastname: FRANCIS
Patient Mobile Number: 0411180493
Patient Date of Birth (dd/mm/yyyy):
23/02/1967
Patient Email:
buddy@australiansandstone.com.au
Patient Gender: M

Patient home address – Number and

street: UNIT 903 23/29 HUNTER
Patient home address – Suburb: HORNSBY
Patient home address – State: NSW
Patient home address – Post Code: 1630

Patient Medicare #: 2107547689

Patient DVANumber: No
Consent to test: Yes

Patient was advised to be tested by a

public health officer/authority? No
Patient was in direct contact with a
COVID-19 exposed person? No
Patient was a possible contact with a
COVID-19 exposed person? No
Patient requires a domestic travel
screening test (e.g. return from an
identified hotspot, going to ski
fields, etc) No
Patient requires a workplace/school
screening test (e.g. healthcare,
quarantine hotel, etc) No
Patient requires test before having
surgery or a planned hospital stay No
Patient requires test as part of
quarantine testing No
Patient requires test for other reason:
Travel work

Temperature/fever No
Chills/sweats No
Cough No
Sore throat No
Blocked/runny nose No
Altered taste/smell No
Headache No
Muscle soreness No
Nausea/vomiting No
Diarrhoea No
Fatigue/tiredness No
Shortness of breath No
Chest pain No