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Chinese General Hospital and Medical Center Institute of Pathology Covid-19 PCR Laboratory Test Request Form

This document is a COVID-19 PCR test request form for Jolaine Ashley Vallo from the Chinese General Hospital and Medical Center Institute of Pathology COVID-19 PCR Laboratory. It collects information such as the patient's name, date of birth, address, contact details, specimen type, symptoms, and consent for the hospital to release test results to health authorities. The form notes that results will generally be issued within 2 days but delays may occur, and the patient waives their privacy rights to allow disclosure of a positive result for contact tracing purposes.

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Jolaine Vallo
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181 views1 page

Chinese General Hospital and Medical Center Institute of Pathology Covid-19 PCR Laboratory Test Request Form

This document is a COVID-19 PCR test request form for Jolaine Ashley Vallo from the Chinese General Hospital and Medical Center Institute of Pathology COVID-19 PCR Laboratory. It collects information such as the patient's name, date of birth, address, contact details, specimen type, symptoms, and consent for the hospital to release test results to health authorities. The form notes that results will generally be issued within 2 days but delays may occur, and the patient waives their privacy rights to allow disclosure of a positive result for contact tracing purposes.

Uploaded by

Jolaine Vallo
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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CHINESE GENERAL HOSPITAL AND MEDICAL CENTER

INSTITUTE OF PATHOLOGY
COVID-19 PCR LABORATORY TEST REQUEST FORM

Accession No. ________________ JULY 9, 2021


Date: _____________________
CS No.: ___________________________ OR No.: ________________________
PATIENT INFORMATION: (PLEASE WRITE LEGIBLY)
Name: (Last, First, Middle) Date of Birth: (MM/DD/YYYY) Age: Gender:
VALLO, JOLAINE ASHLEY, TAMONDONG 07/01/1997 24 yo Female
Room: Contact no.: Email Address:
+639605293195 jolaineashley.vallo.med@ust.edu.ph
Address: (House/Lot No., Street, Barangay, District, Municipality, Province, Region)
Unit 201, 1122 Lourdes Building, Lacson Avenue, Sampaloc, Manila
Employer’s Name (Local) Occupation Place of Work Date and Time of Collection:

Name of Collector:
Specimen Type:
Nasopharyngeal swab Sputum
Oropharyngeal swab Bronchoalveolar lavage
Number of family members living in the same house:

REQUESTING UNIT INFORMATION:


Physicians Name and Signature: Local Government Unit (LGU):
Affiliated Hospital/Clinic: _____________________ __________________________________________
___________________________________________ Contact Person: _____________________________
Tel./Cell No.:_________________ Contact: Number: ___________________________
E-mail add:__________________
Signs and Symptoms Checklist (put a check mark on symptoms experienced within 2 to 14 days)
(This list does not include all possible symptoms. DOH/CDC will continue to update this list as we learn more about COVID-19.)

o Fever or chills o New loss of taste or smell


o Cough o Sore throat
o Shortness of breath or difficulty breathing o Congestion or runny nose
o Fatigue o Nausea or vomiting
o Muscle or body aches o Diarrhea
o Headache

The Laboratory Department shall exert all efforts to issue the test results within 2 days after swabbing for the
Regular PCR Test and within 12 hours after swabbing for STAT-PCR. However, due to inadvertence and unforeseen
circumstances beyond our control, I understand and fully accept that the hospital shall not be liable for unintended
delay in the release of the result of the PCR Test.

I hereby voluntarily waive my rights under the Data Privacy Act of 2012 (R.A. # 10173) in the release of my PCR Test
Result to the DOH and its local partners under the IATF Resolution # 22 Series of 2020, dated April 8, 2020,
Paragraph C, regarding the mandatory public disclosure of the personal information of positive COVID-19 cases to
enhance contact tracing efforts of the government.

I hereby further declare that I indicated any signs and symptoms that I may have in this request form as required by
R.A. 11332.

JOLAINE ASHLEY T. VALLO


__________________________
Signature over Printed Name
LAB-SD/FO-39
REV.6 December 14, 2020

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