Rapid PCR Test Request Form

Email Address


Journey type *

Departure

Arrival

Flight Name *


Flight Number *


PNR NUMBER


Title *


Full Name(As given in ID proof) *


Date of Birth *


Gender *

Male

Female

Transgender

Mobile Number *


Present address *


Present Village/Town/City *


State of Present Residence *


Nationality *


Pin Code *


Did you travel to foreign country in last 14 days *

Yes

No

Passport No. *


Symptoms *

Cough

Breathlessness

Diarrhoea

Sore Throt

Sputum

Nausea

Chest Pain

Abdominal Pain

Vomiting

Heamopytsis

Nasal Discharge

Fever at Evalution

Body Ache

None of Above

Underlying Medical Condition

Chronic Lung Disease

Chronic Renal Disease

Bronchitis

Malignancy

Diabetes

Heart Disease

Hypertension

Asthma

Chronic Liver Disease

None Of Above

Have you ever received Covid 19 Vaccine *

Yes

No

Attached Photo



Attached Passport