PADLAB | eCIF V7

Pre-Registration

Test Purpose:

Travel

Non-Travel

Type of Transaction:

Location:

Type of Test:

Type of Service:

Personal Info

Personal Information

Booking Reference:

Flight Number:

Flight Date:

Itinerary

Passport Number:

Please upload supporting docs

PhilHealth No.:

First Name:

Last Name:

Middle Name:

Birth Date:

Age:

Gender:

Civil Status:

Nationality:

Address Information

Current Address

House No./Lot/Bldg:

Street:

Province:

City/Municipality:

Barangay:

Region:

Email:

Home Phone No:

Cellphone No:

Permanent Address

Same as Current Address

House No./Lot/Bldg:

Street/Purok/Sitio:

Province:

City/Municipality:

Barangay:

Region:

Email:

Home Phone No:

Cellphone No:

Address Outside the Philippines

House No./Lot/Bldg:

Street:

Province:

City/Municipality:

Country:

Place of Work:

Employer's Name:

Employer's /Office Contact No:

Miscellaneous

Date of Interview (MM/DD/YYYY):

Name of Informant (If patient unavailable):

Relationship:

Contact Number of Informant:

Employment

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

I am a health worker

Occupation:

Employer Name:

Work Industry:

Country of Employment

Current Workplace Address

House No./Lot/Bldg:

Street:

Province:

City/Municipality:

Barangay:

Region:

Email:

Home Phone No:

Cellphone No:

Travel History

History of travel/visit/work in other countries with a known COVID-19 transmission 14 days before the onset of signs and symptoms

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 (mm/dd/yyyy):

Arrival Airport:

History of travel/visit/work in other local place with a known COVID-19 transmission 14 days before the onset of signs and symptoms

Place of Origin:

Airline/Sea Vessel/Bus Line/Train:

Flight/Vessel Number/ Bus No.:

Date of Departure (mm/dd/yyyy):

Date of Arrival in the Current (mm/dd/yyyy):

Purpose of Travel:

Contact Tracing

List the names of persons who were with you two days prior to onset of illness until this date and their contact numbers. *If asymptomatic,list the names of persons who were with you on the day you submitted specimen for testing until this date and their contact numbers.

Name	Contact Number

For Additional Close Contact (Include ALL Household Contacts)

Name	Contact Number	Exposure Settings (ex. Household, Work)

Consultation and Admission Information

Did you have previous COVID-19 related consultation?

Date of First Consult (mm/dd/yyyy):

Name of facility where first consult was done:

Was the case admitted in a health facility?

Date of Admission (mm/dd/yyyy):
(Indicate earliest date if admitted in multiple health facilities)

Name of Facility where patient was first admitted:

Region and Province of Facility:

Special Population

Health Care Worker

Name & location of health facility

Returning Overseas Filipino

Country of origin

Foreign National Traveler

Country of origin

Locally Stranded Individual/APOR/Traveler

City, Mun, & Prov of origin

Lives in Closed Settings

Specify type of institution

Exposure History

Clinical Info

Payment

PAYMENT METHOD

Payment Method:

Preview

Pre-Register

Personal Information

Employment

Travel History

Contact Tracing

Consultation and Admission Information

Special Population

Exposure History

Clinical Info

Payment Method

Data Privacy & Recaptcha

DATA PRIVACY CONSENT

In Compliance with the Data Privacy Act (DPA) of 2012 and its Implementing Rules and Regulations (IRR), I am allowing and giving my express consent to Philippine Airport Diagnostic Laboratory (PADLAB) to furnish and provide the details of the results of my PCR/Antigen test, including any and all personal and sensitive personal information I provided to PADLAB in the conduct of my PCR/Antigen test to PADLAB, in accordance with its request dated to PADLAB.

I also acknowledge and warrant that I have given my absolute consent to furnish the result of my PCR/Antigen test, including any and all personal and sensitive personal information I provided to PADLAB in the conduct of my PCR/Antigen test to PADLAB and I hold free and harmless PADLAB from any complaint, suit or damages which any party, including my heirs or assigns, may file or claim in relation to this consent.

Pre-Registration

CONSENT FORM

By signing this consent form, I am hereby agreeing with consent to take the RT-PCR single test service with the PHILIPPINE AIRPORT DIAGNOSTIC LABORATORY, and willing to pay additional fee corresponding to the amount of the RT-PCR Single Testing.

I have carefully read this consent form and we fully understand this contents. This is a release of liability and have signed it on my own free will.

I agree with the terms and condition

Personal Info

Current Address

MUNA Account Detected

Permanent Address

Address Outside the Philippines

Employment

Current Workplace Address

Travel History

Contact Tracing

List the names of persons who were with you two days prior to onset of illness until this date and their contact numbers. *If asymptomatic,list the names of persons who were with you on the day you submitted specimen for testing until this date and their contact numbers.

For Additional Close Contact (Include ALL Household Contacts)

Consultation and Admission Information

Special Population

Exposure History

Clinical Info

Signs & Symptoms

Comorbidities

Payment

Preview

Pre-Register

Personal Information

Employment

Travel History

Contact Tracing

Consultation and Admission Information

Special Population

Exposure History

Clinical Info

Payment Method

Data Privacy & Recaptcha

DATA PRIVACY CONSENT

I agree with the terms and condition