1.  Please complete and sign by a guardian if the test requester is under 18 of age.  如受測者未滿18歲,必須由監護人填寫及簽署。
  2. *Please select appropriate box.  *請在適當方格加上剔號。
  3. #Please delete as appropriate  請删去不適用者

Part A – Test Requester Information 受測者資料

Gender 性別 : *

The test is intended for asymptotic individual COVID-19 testing and is not for the purpose of medical diagnosis or treatment. I am not having any of the following conditions. 本測試只適用於沒有新冠狀病毒病徵的人士,並非用於醫學診斷或治療。我確認我並沒有出現以下任何情況:

  • Severe fever (>38°C)
  • Severe, constant chest pain or pressure
  • Severe dry cough and sore throat
  • Shortness of breath or difficulty breathing
  • Severe tiredness, aches & pains
  • Severe disorientation or unresponsiveness
  • Severe diarrhea or loss of taste or smell
  • 發高燒(>38°C)
  • 嚴重或持續性胸痛或胸口感到壓力
  • 嚴重乾性咳嗽及喉嚨痛
  • 呼吸急促或呼吸困難
  • 嚴重疲累及肌肉酸痛
  • 嚴重神智不清或失去反應
  • 嚴重腹瀉及喪失氣味和味覺
  • Part B - Test Request Information 測試資料

    Specimen type 樣本類別* : *

     ※ Sample needs to arrive in the lab within 24 hours after collection  樣本需要在採集後24小時內到達化驗所 ※

    Part C - Referral Information 轉介資料

    Part D – Disclaimer and Consent 免責聲明及同意書

    The accuracy of this test result is limited by sample handling manner, sample storage duration, condition of transportation, nucleic acid/cells contamination, nature of the viral sequences mutation and etc. Together with the limitation on the latest nucleic acid amplification technology, result conclusions with “False positive”, “False negative” and “Indeterminate” might be arisen. Therefore, it is advisable to take extra caution with the result interpretation due to the test limitations and potential errors. The overall detection limit of the test is 20 copies/µl and RNA copies below this detection limit cannot be guaranteed detectable. It is recommended to cross-reference with a confirmative approach for a definitive result. The sample will be used for test that ordered, after the test has been completed, all personal identification will be stripped and may be selected as the testing internal control purpose. The potential risk of injury during sample collection is outside the scope of our test service. Please seek medical advice if necessary.

    I confirmed that I have read the above disclaimer and consent and I am fully informed about the nature, purpose, procedures and risks of this test. I understand and agree that this test serves for the above-mentioned purpose and acknowledge its limitations and potential errors. I undertake not to use the result of this test or any part thereof for any purpose other than the above-mentioned purpose shall release, indemnify and hold harmless the company, its employees, advisors, and agents against losses and damages arising out of anything connected with this test. I acknowledge and confirm that I have read and understood the (“PICS”) on page 2.
    The English version of these terms and conditions shall prevail whenever there is a discrepancy between the English and Chinese versions.