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  3. Mediclinic Welcare Hospital PCR TEST - Preregistration Form
    1. Al Twar Dialysis Centre Patient Survey
    2. Mediclinic Welcare Hospital PCR TEST - Preregistration Form
Forms

Mediclinic Welcare Hospital PCR TEST - Preregistration Form

Thank you for choosing Mediclinic Middle East.

To request a PCR test, please fill in the information below.

Mediclinic issues all negative PCR tests  results automatically via SMS  and email. Please ensure the Emirates ID/passport number, mobile number, email and date of birth are correct.

All fields in the form are mandatory to coordinate your request.

 

Is PCR test for travel?
Gender
Nationality

Number of patients registered (please list all the patients’ details as indicated)

Choose Drive Through Location
Reason for Test

You should proceed to the emergency department.

You should proceed to the emergency department.

Does the patient present any signs and symptoms?

Does the patient present any signs and symptoms?

You should proceed to the emergency department.

Does the patient have a history of travel in the last 14 days?

Does the patient have a history of travel in the last 14 days?

Did patient have close contact with a person who is under investigation for Covid-19 while that person was ill?

Did patient have close contact with a person who is under investigation for Covid-19 while that person was ill?

Does the patient present with any comorbid conditions? 

Does the patient present with any comorbid conditions?
Is/was the patient Hospitalized?

Is/was the patient admitted to ICU?

Is/was the patient intubated?

Is/was the patient On ECMO?

Is/was the patient admitted to ICU?

Does the patient have any direct contacts?
Have the contacts been tested?
Occupation

Does the patient live in a labor camp?
If (Yes) please fill the fields below.

Have history of being in a healthcare facility ( as a patient, worker, or visitor) during the last 14 days?

Detection Facility:

Type:

Educational Institute Type:

Education Type:

Employer Name
Employer Address

Please complete the following details of your employment at the EXPO

HOME QUARANTINE INSTRUCTION PATIENT ACKNOWLEDGEMENT 

This field is required.
Please add the two figures together (spam protection)