COVID-19 PRE-TRAVEL CONSENT FORM

PLEASE FILL IN CAPITAL LETTERS & WHATS APP YOUR PASSPORT AND TICKET COPY AND THIS FILLED AIRLINE CONSENT FORM AT 0321-202-0003 FOR A HOME VISIT OR WALK IN APPOINTMENT

For ( Airlines, P.I.A, Fly , , , Srilankan Airline, Gulf Air, , Airways) to access your medical records.

Full Name: Date of Birth : (Date/Month

/YEAR) Nationality: Passport No : Airline & Flight # Flight Date & Time in

AM/PM Booking Reference Number

/ Confirmation / PNR CODE Email Address Mobile Number CNIC or NICOP Number

FINAL DESTINATION CITY OF ARRIVAL: ______CONSENT: I have read this form and fully understand the contents of it. I understand that filling in and signing this form gives you permission to give copies of my lab report to the Airline for travelling purpose and report any positive cases to the concerned health department.

TERMS AND CONDITIONS: 1. All amount paid shall be non-refundable. 2. Test results are valid for maximum of 96 hours. Please check the requirement with your airline prior to booking your covid test. For Some countries the requirement is 46 to 72 hours. 3. TAJ , CitiLab & Airline shall not be liable for the outcome of the test. 4. CitiLab or Airline shall not be liable for any damages, claims or other consequences including expenses arising out of any loss, temporary misplacement, delay or damage to the test results once handed over to the passenger. 5. While the said tests are minimally invasive and designed to be conducted with minimum discomfort to the patient, all medical procedures bear some risk.

Your Signature: Date:

Verified by: (for office use only)