FAIRCO MEDICAL & DERMATOLOGY CENTRE COVID 19 PCR TEST REGISTRATION FORM.
The Polymerase Chain Reaction (PCR)  detects the presence of the COVID-19 virus in a sample taken from the respiratory tract of a person if the person is infected at the time the sample is taken. The specimen collected will be sent to an approved laboratory for processing.

Results Sent to Email . Used for Travel and Diagnostics

* Cost must be paid prior to testing - For Results :
    -Within 6-8 Hrs       JA$28,500.00
    -Within 12-15 hrs   JA$25,500.00
    -Within 24 -36 hrs   JA$20,500.00  

*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 *
HOME ADDRESS *
WHAT DATE WOULD YOU LIKE TO ATTEND? (MONDAY-FRIDAY ONLY) *
MM
/
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 collect specimen for this test. The specimen collected will be sent to an approved laboratory for processing. 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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