Doctor /Clinical Referral Testing Request Barcode * Doctor/ Pharmacy Referral * College Pharmacy Guildhall Pharmacy Waller Pharmacy HARLEY MEDIC – College Pharmacy HARLEY MEDIC – Guildhall Pharmacy HARLEY MEDIC – Waller Pharmacy Sussex Healthcare 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 * Phone * Address (include Street and City) * Post Code * SARS-CoV-2 PCR Please Select from Menu SARS-CoV-2 PCR (Same Day) SARS-CoV-2 PCR (Next Day) SARS-CoV-2 PCR (3 hours after Sample Receipt in the Lab) Antigen / Antibodies (SARS-CoV-2 Ab / Ag) Please Select from Menu SARS-CoV-2 Antibodies SARS-CoV-2 Spike Antibodies SARS-CoV-2 Antigen SARS-CoV-2 Rapid Antigen Reason for Testing * Please Select from Menu Work Diagnosis Travel (Fit to Fly) Contact of Confirmed Case Other (please specify below) For Other reason for testing, please specify Clinical Details / Symptoms (Check all that applies) * Asymptomatic Fever Influenza-like Illness Upper Respiratory Tract Infection Cough Pneumonia Other None Onset date of symptoms (if applicable) dd/mm/yyyy For Other Symptoms, please specify Ethnicity: * Please Select from Menu White British White Irish Other White Black African Black Caribbean Other Black Indian Pakistani Bangladeshi Chinese Other Asian Mixed White & Black African Mixed White & Black Caribbean Mixed White & Asian Other Mixed Other 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) * NO 1st Dose Both 1st & 2nd Doses 1st, 2nd & booster doses Comment Fee Payment Fee to be paid by Doctor/Clinic as above If you are human, leave this field blank. Submit
