Electronic application form

A request form for self-sampling

School

Your personal information

Registration is completed

Test request

Test request verification

Škola: {{ skola.skola.value.nazev }}

Name:

Surname:

Nationality:

Health insurance/self-paying pacient:

Insurance number/personal identification number:

For foreigners without an insurance number, fill in the date of birth in the day/month/year format.

Date of sampling:

Contact phone number/cell phone number:

E-mail:

Adress of your residence

Street and house number:

City:

Postal code:

Note to symptoms:

I declare that there is a sample of the person being tested in the test tube.

I agree to the processing of the personal data provided in the form for the purpose of collecting data on the results of testing the sample for the presence of SARS-CoV-2 virus causing COVID-19.

Thank you for the registration, thus saving time for the staff of sampling sites and laboratories.