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Welcome to Covid-19 Testing at Al Zahra Hospital Dubai

 
 

Please provide your mobile no,we will send an OTP

*
Please Select ISD Code
*
Please Enter Mobile No(not include the 0 , e.g - 56XXXXXXX)

# Patient File No Patient Select
All * marked fields are mandatory
 

ContactInfo

*
Please Select ISD Code
*
*
Please Enter Email ID
*
Please Select Residency

Patient Info

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Please Select Title
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Please Enter First Name

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Please Enter Last Name

General Info

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Please Select Gender
*
*
*
Please Select Patient Type

Patient ID

*
Please Select ID Type
*
Please Enter ID No
*
*
Please Select Language

Home Location

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Please Enter Home Address
*
Please Select Home City
*
Please Select Home Dist
*
Please Select Home Area

Work Location

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Please Enter Work Address
*
Please Select Work City

Please Select Work Dist

Please Select Work Area

Occupation

*
Please Select Main Occupation
*
Please Select Occupation Sector
*
Please Select Company/Authority
*
Please Select Student/Educational Staff
*
Please Select Occupation
*
Please Select Educational/Institute Type

*
Please Select If Institute is In Dubai
*
Please Enter Institute Name
*
Please Select Learning Mode
*
Please Select Grade

Labor Camp

*
Please Select If Live in Camp
*
Please Enter Supervisor Number
*
Please Select Camp Location/Zone
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Please Enter Labor Camp Name
*
Please Enter Supervisor Name

Travel History

*
Please Select if travel history in last 14 days

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Please Select Country Travelled

*

*

National ID

*
Please Upload National ID (front side)
*
Please Upload National ID (back side)