Philippine Airport Diagnostic Laboratory System

Patient Profile

Personal Information

Passport No:

Type of Test:

Please upload passport image:

First Name:

Last Name:

Middle Name:

Birthdate:

Age:

Gender:

Civil Status:

Nationality:

Philippine Residence

Address Information

House No./Lot/Bldg:

Province:

City/Municipality:

Barangay:

Region:

Email:

Home Phone No:

Cellphone No:

Add the Emergency Contact Information

Name:

Address:

Contact No:

Employment Information

I am a frontliner(ex. nurse, cashier, guard, teller, utility)

I am a health worker

Occupation:

Employer Name:

Work Industry:

Country of Employment

Travel History

When was the last time you were in the Philippines? <

Port (Country) of Exit:

Port (City) of Exit:

Airline/Sea Vessel:

Flight/Vessel No.:

Date of Departure (mm/dd/yyyy):

Date of Arrival in Philippines:

Arrival Airport:

OFW:

Purpose of Travel:

Exposure History

History of Exposure to known COVID-19 Case 14 days before the onset of signs and symptoms:

Clinical Information

Fever:

Cough:

Sore Throat:

Colds:

Short/Difficulty of breathing:

Other signs/symptoms,specify

Quarantine Facility

Philippine Airport Diagnostic Laboratory System

Patient Profile

Philippine Residence

Employment Information

Travel History

Exposure History

Clinical Information

Preview

Patient Profile

Passport No:

Airport Barcode:

Last Name:

First Name:

Middle Name:

Gender/Sex:

Birthdate:

Age:

Nationality:

Civil Status:

Permanent Address

House No./Lot/Bldg:

Province:

Municipality:

Barangay:

Region:

Home Phone Number:

Cellpone Number:

Email Address:

Emergency Contact

Name:

Address:

Contact Number:

Employement Information

I am a frontliner:

I am health worker:

Occupation:

Employer Name:

Work Industry:

Country of Deployment:

Travel History

When were you last time in the Philippines:

Port (Country) of Exit:

Port (City) of Exit:

Airline/Sea Vessel:

Flight No.:

Date of Departure:

Date of Arrival:

Arrival Airport:

OFW:

Purpose of Travel:

Exposure History

History of Exposure to known COVID-19 Case 14 days before the onset of signs and symptoms:

Clinical Information

Fever:

Cough:

Sore Throat:

Colds:

Short/Difficulty of breathing:

Other signs/symptoms,specify:

Quarantine Facility:

Order Details

Amount to Pay: PHP 4000.00

Type of Test: RT-PCR