IDENTIFICATION SHEET EN

IDENTIFICATION SHEET
(1 PER PERSON)

Gender : M W

Last name :

Birth name :

First name :

Birthdate *:

Residential locations :

Adress in France : (mandatory)
N° / Street :
zip code :
City :

Name of doctor :
Last name : First name :

City :

Analysis :

Phone number reachable within 5 days :

Date of your prescription (if you have one) :

Social security info if you have your paper certificate:

Checkout: Diet: Center:

E-mail adress :

Do you have any symptoms ?

Are you health professional ?

Have you been in contact with a positive person? Yes : No:

CPAM number (only french people) : (mandatory)

* THE SAMPLE ON A MINOR CHILD FOR A COVID19 SCREENING TEST IS CARRIED OUT ONLY IN THE PRESENCE OF A MAJOR REPRESENTATIVE CONSENT TO THE ACT

PLEASE READ THE INFORMATION BELOW BEFORE DOING COVID-19 SCREENING TEST The personal data collected and the medical results obtained are strictly maintained confidential. They will not be transmitted to any third party. We inform you that the results of the tests COVID19 screening and your personal data will be recorded and kept in the IT systems SI-DEP and Contact-COVID, for which the data controller is the MINISTRY OF HEALTH. For more information, * please refer to the display next to the area COVID-19 screening tests. Hard copies are also available to you, free of charge and on simple request. For further information: Website of the Ministry of Health, www.solidarites-sante.gouv.fr or email to: sidep- rgpd@sante.gouv.

IDENTIFICATION SHEET (1 PER PERSON)

IDENTIFICATION SHEET
(1 PER PERSON)