7141313947

LEKARSKE POTVRZENI O VYSLEDKU TESTU PCR NA PRUKAZ SARS-CoV-2

K DOŁOŻENI PRI PREKROĆENI HRANIC ĆESKE REPUBLIKY

MEDICAL CERTIFICATE ON SARS-CoV-2 PCR TESTING RESULTS TO BE SUBMITTED WHEN CROSSING THE CZECH REPUBLIC BORDERS

MEflHHHA flOBIflKA nPO PE3y/lbTAT nflP TECTY 3TIAHO 3 nACnOPTOM SARS-CoV-2 AJ1H nPEfl'RBJlEHHR TIPM TIEPETMHAHHI KOPAOHY MECbKOI PECnYEJlIKM

POTYRZUJI, ŻE / THIS IS TO CERTIFY TH AT/ fllATBEPAWYK), IAO

Prijmem /Surname/ npi3Bnme    .................

Jmeno /Name/lM'a    .................

Datum narożem /Datę of birth/AaTa HapoAweH Mfsto narożem /Place of birth/ Micne HapoAweHHfi

BYL/BYLA TESTOVAN/TESTOVANA NA PCR PRUKAZ SARS-CoV-2 dne / WAS TESTED FOR SARS-CoV-2 ON (DATĘ) / SYB / 6Y/IA flPOTECTOBAHHPl / IIPOTECTOBAHA HA n/lP 3riAHO 3 nACnOPTOM SARS-CoV-2 8 AeHb .................................................

* VYSLEDEK PCR TESTU NA SARS-CoV-2: / SARS-CoV-2 PCR TESTING RESULTS /PE3Y/lbTAT n/IP TECTY BIAHOCHO SARS-CoV-2:

POZITIYNI /Positive/ n03MTHBHHPi    NEGATIYNI /Negative/HErATHBHMfi

V /In/ B

dne /datę/y AeHb

Podpis a razitko potvrzujiciho lekare:

Signature and stamp of a certifying physician: fliAnnc i nenaTKa /linapa, hkhm bma3€ AOBiAKy:

Vysv£tlivky: / Explanatory notę/ npMMiTKH

* Odpovecf vyznaćte kriżkem v prisluśnem obdelniku / Mark the answer with a cross in the appropriate rectangle/ BiAnosiAb no3H3MTe xpecrnKOM y eiAnoeiAHOMy npHMOKyTHMKy