Individual SARS-CoV-2 Testing Request Form

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)

Best Sample Date (Date you will take the test)

Best Sample Time (Time you will take the test)

Vaccination Status (1st , both or None)

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