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COVID ANALYSIS REQUEST FORM

ofsp-coronavirus

Title

Date of Birth

Please complete the following form to help us understand your physical condition.

First name

Last name

Address

ZIP code

Town

Country

IDENTITY-PASSPORT N°

E-mail address

Telephone

Insurance

Insurance No.

TRAVEL date

Appointment date

Appointment time

TEST * Required

PCR

FAST/Antigenic

VACCINE *

Non

Oui

VOYAGE# *

Non

Oui

SYMPTOMATIQUE *

Non

Oui

RAPPORT en anglais *

Non

Oui

ATTESTATION VOYAGE

Non

Oui

I declare that the information I have provided is accurate and complete

TRAVEL# : PCR - Without medical prescription, on-site sampling paid for by the patient. CASH payment CHF 100;Antigen test rapid 50 CHF
NOTE: Holidays and weekends PRICE 150 CHF

Thank you for what you sent !

info@labomed-ge.com HORAIRES / prélèvements sur RDV

Rue de Berne 9 Lundi - Vendredi: 08h00 - 12h00 / 14h00 - 18h00
1201 Genève Samedi et féries : 08h00 - 12h00

+ 41 22 347 40 13 / + 41 79 606 12 71 Prélèvements samedi et féries: maximum 10h

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