Patient Data Registration for COVID-19 Status Certification – Teleconsultation Patient Data Registration for COVID-19 Status Certification – Teleconsultation Patient Data for COVID Certification Photo Identification Document, Passport or alternatively Country’s National Identification Card Serial Number.Upload a Copy of the Data Page of your Passport or both sides of any other types Photo Identification Cards! The Document must contain the Photo of the Person’s face.Choose File (pdf, jpeg, jpg, png, bmp, gif) Patient’s Family NamePatient’s Given NameBirth Name. Is your Name now the same that you had on your Birth Certificate? Yes, my name is the same that I had at Birth. No, I had a name change since Birth due to marriage, voluntarily or for other reasons.Birth Name (Family)Birth Name (Given)Mother’s Maiden Last Name Mother’s Maiden First NameGender – in Hungary only Male or Female Genders are officially recognized. Male FemalePlace of Birth – CountrySelect Country of BirthAfghanistanAland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelauBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Saint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBritish Virgin IslandsBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicDemocratic Republic of the Congo (Kinshasa)DenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyIvory CoastJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacao S.A.R., ChinaMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalestinian TerritoryPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRepublic of the Congo (Brazzaville)ReunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint Martin (Dutch part)Saint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia/Sandwich IslandsSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited Kingdom (UK)United States (US)United States (US) Minor Outlying IslandsUnited States (US) Virgin IslandsUruguayUzbekistanVanuatuVaticanVenezuelaVietnamWallis and FutunaWestern SaharaYemenZambiaZimbabwePlace of Birth – Town, CityDate of Birth, Year.Month.DayPermanent (Home) AddressStreet Name and NumberSupplemental Information about Home Address (e.g. c/o)City, TownState, County, RegionZip (Postal) CodeCountry of Permanent (Home) AddressSelect CountryAfghanistanAland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelauBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Saint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBritish Virgin IslandsBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicDemocratic Republic of the Congo (Kinshasa)DenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyIvory CoastJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacao S.A.R., ChinaMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalestinian TerritoryPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRepublic of the Congo (Brazzaville)ReunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint Martin (Dutch part)Saint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia/Sandwich IslandsSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited Kingdom (UK)United States (US)United States (US) Minor Outlying IslandsUnited States (US) Virgin IslandsUruguayUzbekistanVanuatuVaticanVenezuelaVietnamWallis and FutunaWestern SaharaYemenZambiaZimbabweAdditional Address. Would you like to provide any other, such as Billing or Temporary address? Yes NoAdditional Address. Temporary stay, Hotel or other Accomodation. Billing Address if different from Home Address.Street Name and NumberSupplemental Information about Address (e.g. c/o)City, TownState, County, RegionZip (Postal) CodeCountry of Additional AddressSelect CountryAfghanistanAland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelauBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Saint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBritish Virgin IslandsBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicDemocratic Republic of the Congo (Kinshasa)DenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyIvory CoastJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacao S.A.R., ChinaMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalestinian TerritoryPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRepublic of the Congo (Brazzaville)ReunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint Martin (Dutch part)Saint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia/Sandwich IslandsSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited Kingdom (UK)United States (US)United States (US) Minor Outlying IslandsUnited States (US) Virgin IslandsUruguayUzbekistanVanuatuVaticanVenezuelaVietnamWallis and FutunaWestern SaharaYemenZambiaZimbabweEmail Address that you want to use for Urgent and Confidential Communication.Confirm the Email Address that you want to use for Urgent and Confidential Communication.Mobile Phone number with Country CodeLocal Phone/Mobile NumberThe Reason what you need the COVID-19 Status Certification forHave you been vaccinated against COVID-19 infection? Yes NoThe reason why you have not been vaccinated against COVID-19 infectionFile Upload – Proof / Copy of Covid-19 Vaccinations (including vaccinated person’s Name and all shots with dates).Choose File (pdf, jpeg, jpg, png, bmp, gif) Have you had any COVID-19 testing (PCR, Rapid Antigen) in the past 30 days? Yes NoInitial reason for Covid-19 PCR/Rapid Antigen tests, that became positive:File Upload – Proof / Copy of Covid-19 PCR and/or Rapid Antigen testing over the past 30 daysChoose File (pdf, jpeg, jpg, png, bmp, gif) Are you planning international travel over the next 30 days? Yes NoPlanned Date of International Travel; YYYY.mm.ddPlanned Time of International Travel (24-hour format CET)Did you have any shortness of breath or difficulty breathing in the past 7 days? Yes NoSpecify the time frame of the above marked symptoms! In the past 7 days In the past 3 days In the past 24 hoursDid you have any cough in the past 7 days? Yes NoSpecify the time frame of the above marked symptoms! In the past 7 days In the past 3 days In the past 24 hoursDid you have fever (Temperature > 38,0º Celsius or 100,4º Fahrenheit) in the past 7 days? Yes NoSpecify the time frame of the above marked symptoms! In the past 7 days In the past 3 days In the past 24 hoursDid you have cold symptoms (runny nose, nasal congestion, sore throat) in the past 7 days? Yes NoSpecify the time frame of the above marked symptoms! In the past 7 days In the past 3 days In the past 24 hoursDid you loose your smell or taste sensation in the past 7 days? Yes NoSpecify the time frame of the above marked symptoms! In the past 7 days In the past 3 days In the past 24 hoursMedical Information. Have you had any Prior Illnesses, Hospitalizations, Surgeries? Yes NoPast Medical History. Chronic Diseases, Hospitalizations and Surgeries.Current and Regular Medications and Treatments I do not take any medications now and I do not have any regular prescribed treatments. I take medications now or occasionallyMedications and Treatments. You may choose any or all of the listed. I am being treated only now with some medications, but I do not take them regularly. I take certain medications regularly (for a chronic condition or disease). I only occasionally, but not daily take some medications (for example as needed for headache, backpain).Exact Name and Dosage of Current but not Regular Drugs and other Treatments.Exact Name and Dosage of Regular (Daily) Drugs and other Treatments Exact Name and Dosage of Drugs and Treatments you may use occasionallyHormonal Contraception (Pregnancy Prevention) Yes, I use hormonal contraceptive, tablets or other form (e.g. depo injection, hormone releasing IUD). No, I do not use hormonal contraceptive medications, or hormone releasing IUD.Exact Form, Name and Dosage of Hormonal ContraceptionAre you possibly pregnant (expecting a child) now? Yes NoFirst Day of Your Last Menstrual Period. Estimate the date, if you do not recall exactly.Allergies and Adverse Drug Reactions No known drug allergies or adverse reactions. I had allergies or adverse reactions to drugs.Specify what exactly happened when you took the medication in question causing Allergy (e.g. skin rash, wheels, breathing problem, shock, anaphylaxis).File Upload – Optional. You may attach additional document copies, such as medical reports, lab or imaging testing, prescriptions, immunization cards.Choose File (pdf, jpeg, jpg, png, bmp, gif) Contact Options for Teleconsultation I can be contacted on my Local or European Union Telephone Number I can be contacted on Skype I can call the USA telephone number of the ProviderPreferred Contact Option I want to be contacted on my Local or European Union Telephone Number I want to be contacted on Skype I will try to call the USA telephone number of the ProviderLocal (HU) or EU Telephone Number to be calledSkype NameRequested Date for TeleconsultationTime From (CET 24-hour format)Time To/Until (CET 24-hour format)Other Important Information you would like us to know. Optional field.Additional File Upload – OptionalChoose File (pdf, jpeg, jpg, png, bmp, gif) I have read and agree to the Teleconsultation Terms and Conditions as well as Teleconsultation Prices and Payment Policy. I agree that Teleconsultations may be recorded and disclosed to any third parties involved in my medical care or billing for these services. I have read and agree to the content of the Service Provider’s website, including but not limited to Prices and Fees, General Information and Policy as well as the Privacy Policy. I particularly agree that no refunds may be given for cancelled services or in cases when I was not available for the requested and scheduled visits or services, according to the Terms and Conditions.Signature – Type your full name here as the first step to confirm your Identity. IMPORTANT! After you Submit the Form here you have to open the message sent to your Email and Click on the “Confirm Submission” Button.Submit Form