Home > Request Form > Self-paid COVID-19 Test
New Patients
Regular Patients
Self-paid COVID-19 Test
To request a Self-paid COVID-19 Test appointment, please enter the information below and press the "Send Appointment Request"
button when you have completed the form or if you prefer, you can fill out the same information in our Google Form.
Please click (here) to download the Application Form for Self-paid COVID-19 Test & send back the completed form.
Patient Information
* indicates a required field
Mr. Mrs. Ms. Dr.
First Name *
Middle Name
Last Name *
Name in Chinese
(on NHI card)
Male Female    
Marital Status
Single Married Divorced Widowed
Date of Birth *  (ex. mm/dd/yyyy)
Nationality *
Local Address *
Local Address in Chinese
(on ARC)
City *
Telephone  (ex. 04-xxxx-xxx )
Mobile Number *     (ex. 09xx-xxx-xxx)
E-mail  (ex. xxx@xxx.xxx)
Passport Number *
ARC Number *
(if applicable)
Are you applying for new ARC? *
Yes No    
Appointment Information
Have you been to Jen-Ai Hospital before? *
Yes No
If yes, JAH Registration Card Number
Do you have National Health Insurance card? *
Yes No
Preferred Date of Appointment *  (ex. mm/dd/yyyy)
Departure Date  (ex. mm/dd/yyyy)
Flight No.
Expected date for PCR Report *
PCR - Urgent (Same day, pick-up after 6 PM) – NT$4,500
PCR - Regular (Next day, pick-up after 6 PM) – NT$3,500
Rapid Antigen Test (Same day, pick-up after 1 hour) – NT$1,000
Do you need an interpreter? *
Yes No
If yes, what language?
General Comments:
If you have any questions about your Self-paid COVID-19 Test, please call the
International Medical Center (0963-175-765), Monday ~ Friday, 9 am ~ 5:30 pm.
Please be sure to review your selections carefully before submitting this request. Jen Ai Chang Gung Health International Medical Center looks forward to assisting you and asks that you provide as much information as possible so that we may serve you better when you come in for your appointment.
Please send us the following items: Passport, ARC, NHI card, e-ticket & completed Application Form
for Self-paid COVID-19 Test (preferably in pdf or jpg files) by email to: ipc@mail.jah.org.tw
or if you like, you may upload your documents to our shortened Google Form. Thank you.
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e-mail to: ipc@mail.jah.org.tw
Date Modified: 1/17/2022