COVID-19 Testing

COVID-19 PCR Green List (Day 2) Form

It is government protocol to complete the following form to allow Sloane Square Medical to carry out or supply the required COVID-19 testing. Please submit this form BEFORE making payment for your desired test.

N.B. After submitting the form you will be redirected to the appointment booking page to book your test and make payment. You MUST book your appointment directly after completing the form.

**PLEASE READ**

You must quarantine if NHS Test & Trace informs you that you travelled to England with someone who has tested positive for COVID-19.

What to do if you have been in a country or territory on the red or amber list:

If you have also been in or through a country or territory on the red list in the 10 days before you arrive in England, you must follow the red list rules.

If you have also been in or through a country or territory on the amber list in the 10 days before you arrive in England, and have not visited a country on the red list, you must follow the amber list rules.

If you do not need to follow the red or amber rules then please complete the form below.

Full Name

First Name

Last Name

Date of Birth

Please ensure the UK format for DOB is used e.g. DD/MM/YYYY

Age

Gender

Ethnicity

NHS Number (if known)

Home Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Quarantine Address

Please provide the address where residing during quarantine. This MUST include a UK postcode.

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Email Address

Phone Number

Country

(###)

###

####

First dose vaccination

Have you received the first dose of the COVID-19 vaccination?

Yes

Vaccination Type

Which vaccine have you received?

Second dose vaccination

Have you received the second dose of the COVID-19 vaccination?

Yes

Which green list country are you travelling from?

Please select one of the following green list countries that you are travelling back from.

Date of arrival in the UK

Please provide the date your flight was taken using UK date formatting DD/MM/YYYY.

Flight Number

Flight Time

Hour

Minute

Second

Flight Origin

Passport Number

Date last travelled through non-exempt country

The date on which you last departed from or transited through a non-exempt country or territory, or a non-exempt region of a country or territory, i.e. a destination not on the travel corridors list. Please use UK date formatting DD/MM/YYYY

Last Country Visited

The country or territory you were travelling from when you arrived in the UK, and any country or territory you transited through as part of that journey

Agree and Consent

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I consent for my test to be processed

I have read the Privacy Policy and Terms & Condition’s