Doctor / Clinical SARS-CoV-2 Testing Request Form

Doctor/ Pharmacy Referral

Please re-enter the Clinic / Pharmacy to ensure your RESULT is routed rightly *

Surname *

First name *

Date of Birth (dd/mm/yyyy) *

Gender *

Male

Female

Prefer Not to Say

Email *

Telephone *

Address (include Street and City) *

Post Code *

SARS-CoV-2 PCR

Antigen / Antibodies (SARS-CoV-2 Ab / Ag)

Reason for Testing *

For Other reason for testing, please specify

Clinical Details / Symptoms (Check all that applies) *

Onset date of symptoms (if applicable) dd/mm/yyyy

For Other Symptoms, please specify

Ethnicity: *

Fit to Fly ONLY, Please insert Passport Number below

SPECIMEN INFORMATION (Please Select Sample type) *

Throat/Nasal / Nasopharyngeal Swab

Throat Swab

Nasal Swab

Sample Date dd/mm/yyyy *

Sample Time 24-hour Format *

Vaccination Status (1st, both or None)

Comment

Fee Payment

Fee to be paid by Doctor/Clinic as above