FAIRCO MEDICAL & DERMATOLOGY CENTRE COVID 19 RAPID ANTIGEN TEST REGISTRATION FORM.
The Covid 19 Rapid Antigen Detection Test (RADT) is used for the detect specific antigens to the SARS-CoV-2 virus in a sample taken from the respiratory tract of a person.

Results Sent to Email within One (1) Hour. Used for Travel and Diagnostics

* Cost must be paid prior to testing - JA $5000.00 *NO CHEQUES
                                                               
** Please enter N/A for those questions which do not apply to you.
 
*** Please bring Photo ID for inspection (International ID Accepted)
   
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Email *
QR CODE FOR SHARING
NAME *
CONTACT NUMBER *
ADDRESS *
WHAT DATE WOULD YOU LIKE TO ATTEND? (MONDAY-FRIDAY ONLY) *
MM
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DD
/
YYYY
 WHAT TIME WOULD YOU LIKE TO ATTEND? *
DATE OF BIRTH *
 AGE *
GENDER *
PHOTO ID TYPE (INTERNATIONAL ID ACCEPTED) *
PHOTO ID NUMBER or TRN (PUT N/A IF NOT APPLICABLE) *
WHAT IS THE PURPOSE FOR THE TEST? (CHECK ALL WHICH APPLY TO YOU) *
Required
By submitting this form you are permitting Fairco Medical and Dermatology Centre to perform this test. The results will be shared with the Ministry of Health and/or its assigned officers as necessary for Reportable Diseases or upon request.
A copy of your responses will be emailed to the address you provided.
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