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1st person

Exception *

First name *

Last name *

Identity card / passport number **

app.company ***

Birthdate *

Gender *

E-Mail *

Phone *

Address *

Zipcode *

City *

Country *

2nd person

Exception *

First name *

Last name *

Identity card / passport number **

app.company ***

Birthdate *

Gender *

E-Mail * (Kontakt von 1. Person kopieren)

Phone *

Address * (Adresse von 1. Person kopieren)

Zipcode *

City *

Country *

3rd person

Exception *

First name *

Last name *

Identity card / passport number **

app.company ***

Birthdate *

Gender *

E-Mail * (Kontakt von 1. Person kopieren)

Phone *

Address * (Adresse von 1. Person kopieren)

Zipcode *

City *

Country *

4th person

Exception *

First name *

Last name *

Identity card / passport number **

app.company ***

Birthdate *

Gender *

E-Mail * (Kontakt von 1. Person kopieren)

Phone *

Address * (Adresse von 1. Person kopieren)

Zipcode *

City *

Country *

5th person

Exception *

First name *

Last name *

Identity card / passport number **

app.company ***

Birthdate *

Gender *

E-Mail * (Kontakt von 1. Person kopieren)

Phone *

Address * (Adresse von 1. Person kopieren)

Zipcode *

City *

Country *

* Required
** Optionally fillable, if it is e.g. required for entry or exit.
*** app.company_info

I agree to the performance of a PoC antigen rapid test and the notification of a positive rapid test result to the responsible health authority.

I consent to the performance of a PCR/NAT test and the notification of a positive test result to the responsible health authority.

I agree to the disclaimer against possible injuries.

Yes, I have read the data protection declaration and agree that the data I have provided will be collected and stored electronically. My data will only be used strictly for the purpose of processing and answering my request.

Corona Warn App

I hereby declare my consent to the above averaging the test result and my pseudonymous code to the server system of the RKI so that I can call up my test result with the Corona Warn app. I agree also in the transmission of my name and date of birth to the app, so that my test result in of the app can be displayed as test evidence by name. The information on data protection can be found HERE.

I hereby declare my consent to the transmission of my test result and my pseudonym Codes to the server system of the RKI so that I can call up my test result with the Corona Warn App. The The test result in the app cannot be used as test evidence by name. The information on data protection can be found HERE.

I don't want to use the Corona Warn App

Business hours

Monday

10:00 - 11:30
14:00 - 15:00
Tuesday

10:00 - 11:30
14:00 - 15:00
Wednesday

10:00 - 11:30
14:00 - 15:00
Thursday

10:00 - 11:30
14:00 - 15:00
Friday

10:00 - 11:30
14:00 - 15:00
Saturday

closed
Sunday

closed