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Name:
Address:
Area/Upazila/Police Station:
City/Town/District:
Mobile Number:
Email Address:
How did you find us:
--Select--
Google Search
Facebook
Instagram
Website
Reference
Referred By (if so):
Appointment (Approximate):
Additional Information:
**suspected, reported or confirmed cases of COVID-19 positive individuals in the premises currently or have been in the past 7 days
Are there any?:
No
Yes
If Yes, How many?:
If Yes, Patients:
--Select--
Confirmed - Quarantined
Reported - Quarantined
Suspected in - Isolation
Area to be covered - Square Foot (approx.):
How many floors in the building:
How many floors to be disinfected:
Any Porous Materials on-site?:
No
Yes
Porous Details (if any):
Any Special Compliance?:
No
Yes
Compliance Details(if any):
Lift Available On-Site?:
No
Yes
On-site Water Supply?:
No
Yes
On-site Parking?:
No
Yes
Any Hazardous Materials on-site?:
No
Yes
Hazardous Materials Details(if yes):
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