EcoCare

I hereby confirm that

You must agree before submitting.

RIZIV Code

Please enter 11 digit RIZIV Code

Identification Number

Please enter 11 digit Identification Number

Social Security Number

Please Social Security Number (digit only)

Corona Test prescription Code

Please enter Corona Test prescription Code

Name of House Doctor

Please enter name of House Doctor

House Doctor Phone

Please enter Phone of House Doctor

Veranlassung durch das Gesundheitsamt.

Veranlassung durch einen Hausarzt.

Ich bin Reiserückkehrer.

Sonstige Gründe

Studierende(r)

Hochschulangehörige(r)

andere(r)

Identification Number

Please enter valid Personnel Number

MEP?

Yes

Work Location

Please select work location

Reason for testing?

Staff with high-risk contacts.

Pre- and post-travel for work.

Screening of staff members.

Passport Number

Please enter valid Passport Number

I don't have any symptoms on the moment

I agree that the medical service receive my results and start contract tracing in case of a positive test-result

I agree that this screening can be done by Ecolog

Airline Batch Number

Please enter valid Airline Batch Number

Departure date

Please provide a valid Departure date.

Departure time

Please provide a valid Departure time.

Destination country

Please select destination country.

Transfer passenger?

Yes

Bürger oder Flughafen Passagier?

Bürger

Passagier

Ort des Tests

Memmingen Flughafen

Nürnberger Flughafen

Home Address

Country

Please provide a valid Country.

Street

Please provide a valid Street.

Postal Code

Please provide a valid Postal Code.

City

Please provide a valid City.

Mobile

Please provide a valid Mobile.

Please provide a valid Email.

Address in the next 14 days if different to home address

Address in the next 14 days same as home address

Street

Country

Postal Code

City

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Flight Information

Airport

Please provide a valid Airport.

Flight number

Please provide a valid Flight Number.

Departure date

Please provide a valid Departure date.

Departure time

Please provide a valid Departure time.

Airline

Please provide a valid Airline Company.

Place of departure

Please provide a valid Place of departure.

Seat number

Please provide a valid Seat number 15A.

Companion travelers

Arrivig from a risk country

Yes

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Test type & Pay

Test type

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Create 6 digit password

Please provide a valid Secret.

Please note: After you will submit form QR code will be generate and shown in next screen, using this QR you can see the result of test when ready. If you lose the QR Code you can use the following information to access the test results:

Name
Surname
Date of Birth
Six Digit Password

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Thank you for completing the Application Form. You will receive a unique QR Code in the e-mail provided for a secure access to the COVID-19 Test Results.

ID:

Download

Personal Information

Home Address

Address in the next 14 days if different to home address

Flight Information

Test type & Pay

Thank you for completing the Application Form. You will receive a unique QR Code in the e-mail provided for a secure access to the COVID-19 Test Results.

ID:

Thank you for completing the Application Form. You will receive a unique QR Code in the e-mail provided for a secure access to the COVID-19 Test Results.