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ICMR No. : DANGS001

COVID-19 INFORMATION SHEET

Covid 19 Drive Thru Test

Name: Dr. Dangs Lab
Address: C2/1, S.D.A. Aurobindo Marg Next to Aurobindo Market, New Delhi, 110016, IN
Telephone: +91-9999992020
Price range: $$$$

ICMR Specimen Referral Form for COVID-19 (SARS-CoV2)

Drive Thru Location* :

Vehicle No*

Vehicle Make-Model-Color* :

Available Collection Date
*Only available on next working day :

Choose a Preferred Time
* Exact time slot will be confirmed on call

Additional Blood Tests (if requested):

WE ALSO PERFORM BLOOD TESTS ALONG WITH COVID-19 RTPCR IN OUR DRIVE-THRU CENTRES, IF REQUESTED.
Covid IgG Antibody blood test is available @Rs. 1,600/- to rule out any past exposure/only for surveillance purposes.

SECTION A – PATIENT DETAILS

A.1 TEST INITIATION DETAILS

Doctor Prescription :

Follow up Sample* :

If Yes, Patient ID :

(Prescription is not mandatory , kindly attach if available)

A.2 PERSONAL DETAILS

Name of Patient* :

Age*(Years) :

Age (Months) :

Age (Days) :

Patient in quarantine facility* :

Gender* :

FemaleMaleOthers

Mobile Number* :

Mobile Number belongs to* : SelfFamily

Whatsapp No.

Email ID* :

Present Village or Town :

District of Present Residence :

State of Present Residence :

Nationality* :

Pincode*

Present Address* :

Downloaded Aarogya Setu App* :

(These fields to be filled for all patients including foreigners)

Aadhar No. (For Indians) :

Passport No. (For Foreign Nationals) :

Received COVID-19 vaccine* :

If yes type of vaccine:

Date of Dose 1 :

Date of Dose 2 :

A.3 SPECIMEN INFORMATION FROM REFERRING AGENCY (Not to be filled by Patient)

Specimen type* :

Throat SwabNasal SwabBALETANasopharyngeal swab

Sample ID (Label) :

A.4 PATIENT CATEGORY (PLEASE SELECT ONLY ONE)

A.4.1 Routine surveillance in containment zones and screening at points of entry :

Cat 1: All symptomatic (ILI symptoms) cases including health care workers and frontline workers

Cat 2: All asymptomatic direct and high-risk contacts (contacts in family and workplace, elderly ≥ 65 years of age, those with comorbidities etc

Cat 3: All asymptomatic high-risk individuals

A.4.2 Routine surveillance in non-containment areas :

Cat 4: All symptomatic (ILI symptoms) individuals with history of international travel in the last 14 days

Cat 5: All symptomatic (ILI symptoms) contacts of a laboratory confirmed case

Cat 6: All symptomatic (ILI symptoms) health care workers / frontline workers involved in containment and mitigation activities

Cat 7: All symptomatic ILI cases among returnees and migrants within 7 days of illness

Cat 8: All asymptomatic high-risk contacts (contacts in family and workplace, elderly ≥ 65 years of age, those with co-morbidities etc

A.4.3 In Hospital Settings :

Cat 9: All patients of Severe Acute Respiratory Infection (SARI)

Cat 10: All symptomatic (ILI symptoms) patients presenting in a healthcare setting

Cat 11: Asymptomatic high-risk patients who are hospitalized or seeking immediate hospitalization.

Cat 12: Asymptomatic patients undergoing surgical / non-surgical invasive procedures (not to be tested more than once a week during hospital stay)

Cat 13: All pregnant women in/near labour who are hospitalized for delivery

Cat 14: All symptomatic neonates presenting with acute respiratory / sepsis like illness

Cat 15: Patients presenting with atypical manifestations [stroke, encephalitis, hemoptysis, pulmonary embolism, acute coronary symptoms, Guillain Barre syndrome, Multiple Organ Dysfunction Syndrome,progressive gastrointestinal symptoms, Kawasaki Disease (in pediatric age group)]based on the discretion of the treating physician.

A.4.4 Testing on demand :

Cat 16: All individuals undertaking travel to countries/Indian states mandating a negative COVID-19 test at point of entry

Cat 17: All individuals who wish to get themselves tested

Other: (please specify) * (Select “other" only if the patient doesn’t belong to category 1-17)

Other *(please specify) :

SECTION B- MEDICAL INFORMATION

B.1 CLINICAL SYMPTOMS AND SIGNS

Symptoms :

YesNo

If No please go to B.2 section

Cough :

Diarrhea :

Vomiting :

Fever at Evaluation :

Abdominal Pain :

Breathlessness :

Nausea :

Haemoptysis :

Bodyache :

Sore Throat :

Chest Pain :

Nasal Discharge :

Sputum :

First Symptom :

Date of onset of First Symptom :

B.2 PRE-EXISTING MEDICAL CONDITIONS

Lung Disease :

Malignancy :

Heart disease :

Liver Disease :

Renal Disease :

Diabetes :

Hypertension :

Immunocompromised:

Other underlying conditions: :

B.3 HOSPITALIZATION DETAILS

Hospitalized :

YesNo

Hospital State :

Hospital ID / Number :

Hospital District :

Hospitalization Date :

Hospital Name:

B.4 REFERRING DOCTOR DETAILS

Name of Doctor :

Doctor Mobile No. :

Doctor Email ID :

* Fields marked with asterisk are mandatory to be filled

MANDATORY DOCUMENTS* : (supported file types are .jpg, .jpeg, .png, .pdf, .gif)

Doctor's Prescription

Government ID Proof *

* Kindly carry your Govt. ID Proof as uploaded in Covid Test Booking Form at the time of Testing.

Payment Details* (INR 300 to be paid for the COVID19 Test)

(Only e-payments accepted, no currency notes will be accepted to maintain highest level of infection control)

Paytm QR Code :

NEFT/RTGS Details :

NAME OF THE ACCOUNT : DR DANGS LAB LLP

NAME OF THE BANK : HDFC BANK

BRANCH : Hauz Khas, New Delhi- 110016

CURRENT A/C NO : 50200014788998

IFSC/RTGS CODE : HDFC0000467

Online Payment Detail :
After your sample is collected, you will receive an SMS and Email with Unique ID & Password for our Website Login and making Online Payments on www.drdangslab.com.
Report available in 12-14 hrs.

*Kindly wait for the form to be submitted and do not "Cancel" or refresh the page.

Post submission please wait for a call from our team to confirm the exact timing of the collection

Our Locations
(Sundays closed)

SDA

C2/1, SDA Aurobindo Marg, Next to Aurobindo Market, New Delhi-110016
011-45004200, +91-9999992020
Timing-7:30am to 7:00pm
(Monday-Saturday)

Gurugram

Palm Springs Plaza, Golf Course Road Sector-53, Gurugram-122001
+91-9818881065
Timing-8:00am to 6:00pm
(Monday-Saturday)

Punjabi Bagh

Building No. 25, Ground Floor, Central Market Punjabi Bagh
New Delhi–110026
+91-9810678165
Timing-8:00am to 6:00pm
(Monday-Saturday)

New Friends Colony

D-851, Ground Floor
New Friends Colony
New Delhi-110025
+91-9311225665
Timing-8:00am to 6:00pm
(Monday-Saturday)

Vasant Kunj

12/13 G.F., Vasant Arcade, Nelson Mandela Marg, Vasant Kunj
New Delhi-110070
+91-9910589234
Timings-8:00am to 6:00pm
(Monday-Saturday)

Kamla Nagar

UA No-25, Ground floor Jawahar Nagar, Malka Ganj
New Delhi-110007
+91-9289157434
Timing-8:00am to 6:00pm
(Monday-Saturday)

Jor Bagh

First Floor, 140 Jor Bagh Arya Bhawan, Jor Bagh, New Delhi-110003
+91-9289114439
Timing-8:00am to 2:00pm
(Monday-Saturday)

Khan Market

22 Khan Market, First floor
New Delhi–110003
+91-9810741665
Timing-8:00am to 4:00pm
(Monday-Saturday)

Greater Kailash

GF N36 GK1
New Delhi–110048
+91-9910313567
Timing-8:00am to 4:00pm
(Monday-Saturday)

Vasant Vihar

E 13/11 Basement, Vasant Vihar
New Delhi - 110057
+91-9599191590
Timing-08:00am to 12:00pm
& 05:00pm to 8:30pm
(Monday-Saturday)

Saket Drive Through

Near Muji store
Behind select city walk
+91-9999992020
Prior appointment required
Timing-12:00pm to 2:30pm
(Monday-Saturday)

We would love to hear from you !

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