Doctor /Clinical Referral Testing Request Barcode * Doctor/ Pharmacy Referral * College PharmacyGuildhall PharmacyWaller PharmacyHARLEY MEDIC – College PharmacyHARLEY MEDIC – Guildhall PharmacyHARLEY MEDIC – Waller PharmacySussex 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 MenuSARS-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 MenuSARS-CoV-2 AntibodiesSARS-CoV-2 Spike AntibodiesSARS-CoV-2 AntigenSARS-CoV-2 Rapid Antigen Reason for Testing * Please Select from MenuWorkDiagnosisTravel (Fit to Fly)Contact of Confirmed CaseOther (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 MenuWhite BritishWhite IrishOther WhiteBlack AfricanBlack CaribbeanOther BlackIndianPakistaniBangladeshiChineseOther AsianMixed White & Black AfricanMixed White & Black CaribbeanMixed White & AsianOther MixedOther 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) * NO1st DoseBoth 1st & 2nd Doses1st, 2nd & booster doses Comment Fee Payment Fee to be paid by Doctor/Clinic as above If you are human, leave this field blank. Submit
