MANDATORY CUSTOMER RECORD FORM
ALLTEST COVID-19 AG SALIVA RAPID TEST (SELF-TESTING) CUSTOMER RECORD

Customer details are to be provided by the instruction of the Medical Devices Authority for recording purposes only. Any incomplete or false information can be fined by the Medical Devices Authority. All Personal Data Privacy Act policies will be in place to protect your personal data.
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Name *
Phone Number *
Email Address
Quantity Test Purchase *
Pharmacy/Clinic/Healthcare Institution Name *
Purchase Date and Time *
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Time
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