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.mainland_travel_permit_no}}
{{form.passport_no}}
{{form.other_cert_name}}
{{form.other_cert_no}}
{{form.real_birthday}}
{{form.username_en_last}}
{{form.username_en_first}}
{{form.username_zh}}
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 purposes）
檢測者個人資料 Personal Details of Examinee
註：香港身份證號碼、回鄉證號碼和護照號碼至少填寫一個、亦可填寫多於一個證件號碼。
Note: Fill in at least one of Hong Kong Identity Card Number, Home Visit Permit Number and Passport Number，or can fill in more than one document number.
 男性 Male 女性 Female
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