Application form PCR SARS-CoV-2

form.antibot { display: none !important; } You must have JavaScript enabled to use this form.

Corona Test Prescription Code (CTP Code) *

If you're a departing traveller, please fill 0000-0000-0000-0000 in as CTP code. For refunded tests, this CTP code must NOT be older than 10 days on the date of COVID-19 PCR collection!

Indication *

Patient Details

Date of birth *

Sex *

First Name *

Name *

Address *

Postal Code *

Place *

Country *

National registration number patient

Language of the report *

ENG

Mail address patient *

Cellphone number patient *

Name of GP

Patient Statements

The patient indicates that he is aware of the COVID guidelines regarding travel abroad, and has informed himself about the requirements per country of destination (https://www.info-coronavirus.be/en/)
The patient acknowledges that the laboratory is NOT responsible for the delivery of the EU Digital COVID Certificate. The patient indicates that he is aware of the correct procedures regarding the EU Digital COVID Certificate. These must be requested via the CovidSafeBE app or sites such as Covidsafe.be, My Citizen Profile & My Health.
The patient agrees to pay the cost price of the analysis (50 €) if the supplied CTP code was incorrectly or not passed on or does not give rise to reimbursement by the health insurance companies.
The patient indicates that he is aware that these results will not appear on the COZO health care platform in the absence of the data from a RIZIV-recognized doctor.
The patient acknowledges that the laboratory cannot be held financially responsible for additional costs due to late reporting or administrative errors.

Leave this field blank

U bent hier