FAR EASTERN MEMORIAL HOSPITAL
Out-of-pocket COVID-19 PCR testing
QR code for rapid line
*Required
*Date to get tested (within 14 days)
*Time to get tested
*Medical Information Form

*Please fill in the ID number/Taiwan photo ID/ARC number or Passport Number
Taiwan photo ID/ARC number
* Passport Number
Mainland travel permit for Taiwan residents (MTPs) number/Mainland Resident Travel Permit number MTPs number or Mainland Resident Travel Permit number is required
*Date of birth
*Taiwanese citizen
*Foreign Nationality
*Foreign Nationality-others
Passport photo copy (in jpg/jpeg/png)
*Chinese name (as shown in the passport)
*English name (as shown in the passport)
*Contact number (numbers only)
*Residential address
Emergency contactor
Emergency contact number (numbers only)
Relationship
*Destination (please type “no” if does not have)
Estimated date of departure
Flight number
*Reason to get tested
*
In order to protect everyone, please fill out the questionnaires.
*Traveling within the past 14 days
*
*Occupation
*
*Contacting history within the past 14 days
*Cluster
*Any display symptoms

Total:dollars
年度考績時間為: