Laboratory name : Ruby Hall Clinic *
HinjawadiPimple Saudagar

Corporate Name *

Patient Name *

Date of Birth *

Gender *MaleFemale

Occupation *

Mobile Number *

Mobile Number belongs to *SelfFamily

Email Id *

Nationality *

Aadhar No. (for Indians)

Passport No. (for Foreign Nationals)

State of Present Residence *

District of Present Residence *

Present Patient Address ( Full Address ) *

Present Village / Town *

Pin Code *

Downloaded Aarogya Sethu App * YesNo

Sample collected from

Patient in Quarantine Facility * YesNo

Where was the patient quarantined * HomeHospitalNA

Date of arrival in India (If applicable)

Did you travel to any foreign country in last 14 days *YesNo

Place of Travel

Respiratory Infection SARI *YesNo

Respiratory Infection Influenza like illness * YesNo

Are you a healthcare worker involved in managing COVID-19 patient * YesNo

SRF ID (Applicable to Lab only)

Date of Sample Collection *

Date of Sample Received (Applicable to Lab only)

Sample Type (NPs + OPs) NPs+OPs

Sample ID (For Lab use only)