Covid-19 Rt-Pcr Request Form

COVID-19 RT-PCR REQUEST FORM

Date (MM/DD/YY): ______

Patient Name: ______Last Name First Name/s Middle Name

Date of Birth (MM/DD/YY): ______Age: ______Gender: ☐Male ☐ Female

Contact No.: ______Email address: ______

Address: House/Bldg./Purok/Block No. ______Street Name, Barangay Name ______Municipality/City ______Province ______Zip Code ______

Reason for the Test:

☐ Previously diagnosed with COVID-19 by RT-PCR, please specify testing date: ______☐ Diagnosed as COVID-19 positive by a RAPID TEST ☐ CLEARANCE FOR WORK ☐ CLEARANCE FOR SURGERY ☐ HEALTHWORKER ☐ HIGH RISK GROUP (Choose one): ☐ Pregnant ☐ Elderly ☐ with underlying medical conditions ☐ SCHEDULED FLIGHT (Choose one): ☐ Within the Country ☐ Outside the Country ☐ EXPOSED TO A COVID PATIENT ☐ EXHIBIT SYMPTOMS OF COVID-19 ☐ OTHERS, please specify: ______

C O N S E N T F O R M

I have been informed about COVID-19 (SARS CoV-2) RT-PCR Testing, its benefits and its limitations and hereby certify that all information provided on this form are true and reliable personal information. I also authorize Greencity Medical Center (GMC) to forward any and all information as may be required by law through an appropriate government agency including but not limited to the Department of Health. I also agree to the use of my personal and clinical data by my physician and/or the laboratory for the purposes of auditing, quality assurance and research provided that I remain anonymous and unidentifiable from any reports or publications. Further, I understand that any discomfort felt during the collection of the specimen is unintentional on the part of the allied health professional involved in the process and varies depending on one’s pain threshold. In the event that, repeat sample collection may be required, I also give my full consent and shall coordinate and cooperate with GMC on when and where the former shall

Jose Abad Santos Avenue, Brgy. Dolores, City of San Fernando, Pampanga Trunklines: 649-8701; 649-8702 /Celphone #: 0919 068 8846 / PCR LAB: 649-8701 local 139 Email: [email protected]/[email protected] be conducted. In compliance to RA 10173, also known as the Data Privacy Act of 2012, I formally grant GMC and its authorized representative/s, permission to scrutinize two (2) of my valid IDs and take a photo of myself at the PCR drive thru for documentation purposes.

______Patient’s signature over printed name/Date

PHYSICIAN REQUEST FORM TEST: COVID -19 Date(MM/DD/YY): ______

Patient Name: ______Surname First Name Middle Name

Date of Birth (MM/DD/YY): ______Age: ______Sex: ( ) M ( ) F Contact Number: ______Email Address: ______Address: ______

Indication for the test: ______Symptoms:

Type of Specimen: ( ) Oropharygeal / Nasopharygeal Swab ( ) Sputum ( ) Brocho-alveolar Lavagae ( ) Others, specify : ______Date collected (MM/DD/YY): ______Time Collected: ______(AM/PM) Date of sample Receipt: ______

PHYSICIAN’S INFORMATION

Physician’s Name: ______Physician’s Contact number: ______Physician’s Emil Address: ______

HOSPITAL / LABORATORY INFORMATION Laboratory / Hospital Name: ______Address: ______Contact Person:______Position:______Contact Number: ______Email Address: ______Philippine Integrated Disease Surveillance and Response Case Investigation Form Coronavirus Disease (COVID-19)

Disease Reporting Unit/Hospital: Name of Investigator: Date of Interview:

1. Patient Profile

Last Name First Name Middle Birthday (mm/dd/yyyy) Age Sex: ( ) Male Name ( ) Female

Occupation Civil Status Nationality Passport No.

2. Philippine Residence 2.1. Permanent Address

House No./Lot/Bldg. Street/Barangay Municipality/City Province

Region Home Phone No. Cellphone No. Email address

2.2. Current Address House No./Lot/Bldg. Street/Barangay Municipality/City Province Region Home Phone No. Work Phone No. Other Email address 3. Address Outside the Philippines (for Overseas Filipino Workers and Individuals with Residence Outside the Philippines) Employer's Name: Occupation Place of Work:

House No./Bldg. Name Street City/Municipality Province Country: Office Phone No.: Cellphone No.: 4. Travel History

History of travel/visit/work in other countries with a known ( ) Port (Country ) of exit: COVID-19 transmission 14 days before the onset of your signs Yes and symptoms: ( ) No Airline/Sea vessel: Flight/Vessel Number: Date of Departure (mm/dd/yyyy) Date of Arrival in Philippines:

5. Exposure History History of Exposure to Known COVID-19 Case 14 days before ( ) Yes ( ) If yes: Date of Contact with Known COVID-19 the onset of signs and symptoms: No Case (mm/dd/yyyy): ( ) Unknown Have you been in a place with a ( ) Yes If yes: Place: ( ) Work place ( ) Health facility known COVID-19 transmission 14 ( ) No ( ) Social gathering ( ) Religious gathering days before the onset of signs and ( ) Unknown ( ) Others: specify type: ______symptoms: Date when you have been in that place: Name of the place: List the names of persons who were with you during this (these) Name Contact number occasion(s) and their contact numbers: 1. Use the back part of this sheet when needed 2. 3. t 6. Clinical Information

Disposition at Time of ( ) Inpatient ( ) Outpatient ( ) Discharged ( ) Died ( ) Unknown Repor ( Date of Onset of Illness (mm/dd/yyyy): Date of Admission/Consultation (mm/dd/yyyy): Fever °C ) Cough ( ) Sore throat ( ) Colds ( ) Shortness/difficulty of breathing Other signs/symptoms, specify Is there any history of other illness? ( ) Yes ( ) No If YES, specify: Chest X-ray done? ( ) Yes ( ) No Are you pregnant? ( ) Yes ( ) No If yes, when? _ _ _ _ LMP _ _ Assessed as High Risk? ( ) Yes ( ) No CXR Results: Pneumonia ( ) Yes ( ) No ( ) Pending Other Radiologic Findings: 7. Specimen Information Date if YES, Date Collected sent to Date received in RITM PCR Specimen Collected Virus Isolation (mm/dd/yyyy) RITM (to be filled up by RITM) Resul Result (mm/dd/ t yyyy) / ( ) Serum / / / / /

/ ( ) Oropharyngeal/ / / / / / Nasopharyngeal swab / ( ) Others / / / / /

8. Classification ( ) Suspect ( ) Probable Case ( ) Confirmed Case Case 9. Outcome Date of Discharge (mm/dd/yyyy): Condition on Discharge: ( ) Improved ( ) Recovered ( ) Transferred ( ) Absconded ( ) Died Name of Informant: (if patient not available) Relationship: Phone No.

Cont. of Exposure History List of Close Contacts Name Contact number 1. 2. 3. 4. 5. List the names of persons who 6. were with you during this (these) 7. occasion(s) and their contact 8. numbers: 9. Use the back part of this sheet when needed 10. 11. 12. 13. 14. 15. 16. 17.

18.

19.

20.

COVID-19 Case Definitions: 1. Suspect case – is a person who is presenting with any of the conditions below. a. All SARI cases where NO other etiology fully explains the clinical presentation. b. ILI cases with any one of the following: i. with no other etiology that fully explains the clinical presentation AND a history of travel to or residence in an area that reported local transmission of COVID-19 disease during the 14 days prior to symptom onset OR ii. with contact to a confirmed or probable case of COVID-19 in the two days prior to onset of illness of the probable/confirmed COVID-19 case until the time the probable/confirmed COVID- 19 case became negative on repeat testing. c. Individuals with fever or cough or shortness of breath or other respiratory signs or symptoms fulfilling any one of the following conditions: i. Aged 60 years and above ii. With a comorbidity iii. Assessed as having a high-risk pregnancy iv. Health worker 2. Probable case – a suspect case who fulfills anyone of the following listed below. a. Suspect case whom testing for COVID-19 is inconclusive b. Suspect who tested positive for COVID-19 but whose test was not conducted in a national or subnational reference laboratory or officially accredited laboratory for COVID-19 confirmatorytesting 3. Confirmed case – any individual, irrespective of presence or absence of clinical signs and symptoms, who was laboratory confirmed for COVID-19 in a test conducted at the national reference laboratory, a subnational reference laboratory, and/or DOH-certified laboratory testing facility.

WAIVER OF DATA PRIVACY CONSENT/ AGREEMENT I______of legal age, Filipino married/single and a resident of ______do hereby state:

1.] That I conform and agree that GREENCITY MEDICAL CENTER recognizes its responsibilities under the Republic Act No. 10173 (Act), also known as the Data Privacy Act of 2012, with respect to the data they collect, record, organize, update, use, and consolidate from me;

2.] That I hereby acknowledge that the personal data and result of my COVID 19 test obtained by GREENCITY MEDICAL CENTER is entered and stored within the hospital’s authorized information and communications system and will only be accessed by the GreenCity Medical Center, the Department of Health (DOH) and the Municipality and Local Government of Pampanga and other concerned agencies and entities;

3.] That I hereby agree and give my full, free and voluntary consent that the information collected and stored in the portal shall only be used by GreenCity Medical Center, the Department of Health (DOH) and the Municipality and Local Government of Pampanga and other concerned agencies for the following purposes: 1. Processing and reporting of patients data and results related to the COVID-19 RT PCR test. 2. Announcements of health programs and courses to prevent the spread of the disease; and 3. Other activities organized by the Department of Health and the Local Government Unit;

4.] That during the pendency of the analysis of my confirmatory result for the presence of COVID 19 disease by GREENCITY MEDICAL CENTER, I hereby undertake to quarantine myself in any government facilities and/or isolate myself from any person to prevent infecting other people; and that according to government regulations, those who did not underwent self quarantine will be held liable if the result turns positive.

5.] That I hereby release GREENCITY MEDICAL CENTER, its officers, directors, stockholders, employees and other personnel from any liabilities from the information revealed and disclosed in relation to the test and result that was conducted upon me to the Department of Health, the Municipal & Local Government Unit or to any concerned agencies or persons;

6. ] That I have read the hospital’s Data Privacy Statement and express my consent in favor of the Hospital to collect, record, organize, update or modify, retrieve, consult, use, consolidate, block, erase or destruct my personal data as part of my information. P Pursuant to the provisions of the Republic Act No. 10173 of the Philippines, Data Privacy Act of 2012 and its corresponding Implementing Rules and Regulations.

City of San Fernando, Pampanga ______2020

______NAME OF PATIENT WITNESSED BY ______

WAIVER OF DATA PRIVACY CONSENT/ AGREEMENT

I______of legal age, Filipino married/single and a resident of ______do hereby state:

4.] That while waiting for the confirmatory result for the presence of COVID 19 disease by GREENCITY MEDICAL CENTER, I hereby undertake to do a HOME QUARANTINE for the next 14 days or if required, quarantine myself in any government facilities and/or isolate myself from any person to prevent infecting other people; and that according to government regulations, those who did not underwent self quarantine will be held liable if the result turns positive.

City of San Fernando, Pampanga ______2020

______NAME OF PATIENT WITNESSED BY ______