您確定資料準確無誤嗎？
Are you sure that the information is correct?
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{{form.id_card}}
{{form.passport_no}}
{{form.other_cert_name}}
{{form.other_cert_no}}
{{form.real_birthday}}
{{form.username}}
男性 Male
女性 Female
一經確認，無法更改
Once confirmed, it cannot be changed
新型冠狀病毒核酸檢測登記表格
Registration Form of COVID-19 RNA Test
（出境用 for outbound）
檢測者個人資料 Personal Details of Examinee
註：身份證號碼和護照號碼至少填寫一個。Note: Fill in at least one ID number and passport number.
 男性 Male 女性 Female (Lab Code: 21108)：出境到中國 (Lab Code: 21112)：出境到美國、新加坡、其他國家
風險評估問卷 Risk Assessment Questionnaire
  1. 過去14天您曾經居住或到訪過的城市 Cities that you have lived or visited in the past 14 days:
    中國內地城市，請指明 City in Mainland China, please specify: 其他，請指明 Others, please specify: 過去的14天內我並沒有離開香港 I have not left Hong Kong in the past 14 days.
  2. 過去14天內您有否有與新型冠狀病毒確診者緊密接觸? Have you had close contact with COVID-19 infected person in the last 14 days?
    有 Yes 沒有 No
  3. 您的居住社區/工作環境有否新型冠狀病毒確診個案? Are there any confirmed cases of COVID-19 infection in the neighbourhood of your home /office?
    有，請指明 Yes, please specify: 沒有 No
  4. 您有以下徵狀嗎? Do you have any of the following Symptoms?
    發燒 Fever 呼吸困難 Difficult to breathe 咳嗽 Cough 肌肉痠痛 Muscle Pain 肚瀉 diarrhea 胸口鬱悶 Chest Congestion 其他，請指明 Yes, please specify: 以上皆非 None of the above Symptoms
聲明Declaration
(如檢測者未滿18歲，須由家長或監護人簽署To be signed by a parent or guardian if the examinee is below 18)
本人確認上述所提供的資料屬於提交樣本的檢測者本人並準確無誤；且本人已閲讀及同意後頁所載的【收集個人資料聲明】。本人願意收取任何市場推廣資訊。
I confirm that the information provided above belongs to the examinee submitting the specimen and is accurate. I have read and consent to the "Personal Information Collection Statement"; and agree to receive marketing, advertising and promotional information. 本人確認上述所提供的資料屬於提交樣本的檢測者本人並準確無誤； 且僅用於檢測及後續個案跟進之用。本人並不同意收取任何市場推廣資訊。
I confirm that the information provided above belongs to the examinee submitting the specimen and is accurate. I understand that the information provided shall be used for testing and case follow-up purposes only. I do not consent to receive marketing, advertising and promotional information.
確認並提交 Confirm and Submit
DNA WeCheck Limited / Young+ Wellness