ACCOMPANYING SHEET FOR CLINICAL SAMPLE FOR COVID TEST-19

    ACCOMPANYING SHEET FOR CLINICAL SAMPLE FOR COVID TEST-19

    BYSINESS DATA

    COMPANY NAME:

    SURNAME*:

    FIRST NAME*:

    FATHERS's NAME*:

    AGE*:

    ADDRESS*:

    PHONE NUMBER*:

    NATIONALITY*:

    AMKA*:

    SEND RESULTS BY e-mail*:

    RECIPIENTS OF RESULTS FROM THE SECRETARIAT OF THE ATHENS CLINIC:

    EXPOSURE TO THE NEW CORONO VIRUS IN THE 14 DAYS BEFORE SAMPLING


    CLOSE CONTACT WITH CONFIRMED CASE OF COVID-19*;

    TRAVEL HISTORY . IF TES, WHERE:

    AUTHORIZATION TO SEND COVID 19 TEST RESULTS

    By now I’m authorizing the doctor (or any other responsible person) indicated by the company with the above surnames in the ATHENS HOSPITAL- ΓΕΩΡΓΙΑΔΗΣ-ΔΡΑΚΟΠΟΥΛΟΣ ΙΚΕ, as it receives the results of COVID-19 and I know that my results for the COVID-19 will be notified by the ATHENS HOSPITAL , in ΕΟDΥ, patient register COVID-19 and in any other authority,register in accordance with the provisions of the current legislation.


    Date:

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