Patient Agreement to Covid-19 Test

Thank you for your enquiry about our COVID-19 PCR testing.

Before submitting your request below, please ensure that you have read and understood all requirements for travel here and for further information please check our FAQ

Patient Agreement to Covid Swab

"*" indicates required fields

Name as per NRIC/FIN/Passport*

Prefix First Last

Date of Birth*

Address in Singapore*

Street Address Floor and Unit # ZIP / Postal Code

Type of Swab Test*

What is the reason for your Test?*

PLEASE SELECT THE TYPE OF APPOINTMENT YOU REQUIRE**

Dropping off Sample/s

Do you have any medical conditions where you should not have a nasal swab?*

This includes the risk of nose bleed, clotting problems, deviated nasal septum, previous nasal or base of skull fracture/injury.

Select if Yes*

Preferred Date of Appointment*

Please check with your destination country PCR/ART testing requirements.

Time*

Additional Travelers requiring Swab on the same itenary*

Traveler 1 NRIC/FIN card*

Max. file size: 50 MB.

Traveler 1 Copy of Passport*

Max. file size: 50 MB.

Traveler 2 NRIC/FIN card*

Max. file size: 50 MB.

Traveler 2 Copy of Passport*

Max. file size: 50 MB.

Traveler 3 NRIC/FIN card*

Max. file size: 50 MB.

Traveler 3 Copy of Passport*

Max. file size: 50 MB.

Traveler 4 NRIC/FIN card*

Max. file size: 50 MB.

Traveler 4 Copy of Passport*

Max. file size: 50 MB.

Traveler 5 NRIC/FIN card*

Max. file size: 50 MB.

Traveler 5 Copy of Passport*

Max. file size: 50 MB.

Traveler 6 NRIC/FIN card*

Max. file size: 50 MB.

Traveler 6 Copy of Passport*

Max. file size: 50 MB.

Applicant Email Address*

Please note that this email address will be used for all additional travellers.

Applicant Contact Number*

Clinic*

Agreement*

By signing this form, I agree to the following conditions set out below:

I confirm that the requested appointment meets my destination country's requirements

I confirm that I have provided all required documentation

I confirm that I have declared any contra-indications to undergo nasal swabbing

I acknowledge that IMC accepts no responsibility or liability for any missed flights due to inconclusive results or any other unpredictable factors that may occur (for travellers)

I understand if my Covid Test returns positive, any travel will be prohibited and MOH will be notified

Signature*

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Patient Agreement to Covid Swab

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