天主教輔仁大學附設醫院
Fu Jen Catholic University Hospital
Out-of-pocket COVID-19 PCR testing
Check appointment
*
Required
繁體中文
English
*
Date to get tested (within 14 days)
*
Time to get tested
*
Medical Information Form
Yes
No
*
Type of case
Priority.
General.
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Please select the required certificate on the report and fill in the certificate code correctly:
Indentity card
Resident certificate
Passport No.
MTPs
Mainland Resident Travel Permit number
Taiwan photo ID/ARC number
*
Passport No.
Mainland travel permit for Taiwan residents (MTPs) number/Mainland Resident Travel Permit number
*
Double Confirm:
*
Taiwanese citizen
Taiwanese citizen
Not Taiwanese citizen
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Foreign Nationality
New Zealand
AFGHAN
ARGENTINA
AUSTRALIAN
OSTERREICH
BELGE
BANGLADESHI
REPUBLIC OF BALARUS
BELIZEAN
BRASILEIRO(A)
CANADIAN
Switzerland
CHINESE
CZECH REPUBLIC
DEUTSCH
DANISH
ETHIOPIAN
ESPANOLA
Finland
Francaise
BRITISH CITIZEN
GAMBIAN
HELLENIC
INDONESIA
INDIAN
IRISH
ISLAMIC REPUBLIC OF IRAN
ITALIANA
JAPAN
KAZAKHSTAN
CAMBODIAN
REPUBLIC OF KOREA
MYANMAR
MONGOLIA
MALAYSIA
Nederlandse
NAPALESE
FILIPINO
POLISH
PORTUGUESA
SWEDISH
THAI
REPUBLIC OF CHINA (TAIWAN)
UKRAINE
UNITED NATIONS
UNITED STATES OF AMERICA
VIETNAMESE
SOUTH AFRICAN
OTHERS
*
Foreign Nationality-others
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Chinese name (as shown in the passport)
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English name (as shown in the passport)
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Date of birth
*
Statutory agents
*
Sex
Male(Mr.)
Female(Ms.)
Other
*
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 of application
People who need to hasten home for the funeral(
Family member
Family lives abroad )or visit patient during home quarantine.
People who need to entry other country/area for visiting relatives living outside.
Business
Taiwan CDC defined short-term business travelers.
Study aboard.
Foreigner departure
Families of people applied to departure.
With consent of COVID-19 centeral epidemic command center.
Other.
：
*
For the epidemic prevention, please answer the following question
*
Travel History Have entered from countries/areas affected by COVID-19
No
Yes：have entered from countries/area affected by Covid-19
Please fill in [Starts on]、[Countries visited]
Starts on：
～
Countries visited：
*
Have you had fever symptom or listing symptoms during the past 14 days.
Please fill in [symptom]
No.
Yes:
Fever (≥38℃)
Cough
Sore thorat
Runny/stuffy nose
Diarrhea
Loss of smell or taste
Shortness of breath
Malasise
Other
：
*
*
Have been to hospitals, clinics for treatment during the past 14 days
No
Yes,
Required
Date of Examination：
Hospital：
Department :
*
Occupation
Required
No
Yes：
Medical personnel
Transportation (e.g. taxi, bus etc.)
Aviation industry (aircraft crew)
Tourism industry or Hotel industry (e.g. tour guide, hotel housekeeper etc.)
Restaurant business
Agriculture、 Forestry、 Fishery and Animal Husbandry
Service industry
Student
Others
：
*
*
Contact History Have been in contact with any suspected or confirmed Covid-19
No
Yes,other：
：
*
*
Cluster Have you been in large crowds (in clusters) in the past month?
No
Living with your family Your family members are currently：
Undergoing isolation at home.
/
Undergoing quarantine at home
/
Managing their own health until.
Required
month/date
Family members also have a fever or respiratory symptom.
Friends also have a fever or respiratory symptoms.
Colleagues also have a fever or respiratory symptoms.
I have understood the entry regulations of the authorities concerned(includingTCDC, MFA, MAC), checked the filled-in data are correct, and accepted selfing paying the examination fee.
I agree that the above-mentioning data are uploaded to "Healthcare Passbook" by Fu Jen Catholic Unversity Hospital.
I autherize the Fu Jen Catholic University Hospital to dowload the above-mentioning data from "National Health Insurance".
Yes，
：Agree that if the TOCC epidemic information is seen in the hospital within 28 days, it will be brought into the medical record.
Yes，
：Comply with government policy Agree Contact number upload.
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