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 (to meet 48 /72 Hours PCR test requirement)

Best Sample Time (to meet 48 /72 Hours PCR test requirement)

Vaccination Status (1st , both or None)

Comment