COVID-19 Testing

COVID-19 PCR Test-to-Release (Day 5) 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.

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

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