0207 838 6180
contact@cpmedicalclinic.com
61-63 Sloane Avenue, Chelsea, SW3 3DH
Open 6 days a week until late!
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0207 838 6180
contact@cpmedicalclinic.com
Form
Home
Form
First Name
*
Last Name *
*
Date of birth
*
Day
Month
Year
Gender
*
Male
Female
Others
Prefer Not to Answer
NHS number
*
Ethnicity
*
BLACK - AFRICAN
BLACK - CARIBBEAN
OTHER / MIXED
BLACK - OTHER
CHINESE
PAKISTANI
INDIAN
BANGLADESHI
WHITE
WHITE AND ASIAN
WHITE AND BLACK AFRICAN
WHITE AND BLACK CARIBBEAN
WHITE BRITISH
WHITE IRISH
WHITE OTHER
Home Address
*
Including Post Code
The address provided to the test provider as the place where the international arrival is able to receive a confirmatory test
*
Including Post Code
Phone Number
*
(only in the case of SARS-CoV-2 positive or indeterminate results)
Email
*
(only in the case of SARS-CoV-2 positive or indeterminate results)
Whether or not the individual has received a vaccine against SARS-CoV-2
*
Yes
No
Passport number or travel document number
*
Coach number, Flight number or vessel name
(as appropriate)
The date on which they last departed from or transited through a country or territory outside the common travel area
*
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Month
1
2
3
4
5
6
7
8
9
10
11
12
Year
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
The country or territory they were travelling from when they arrived in the UK
*
Any country or territory they transited through as part of that journey
Test booking reference
*
The date of their arrival in the UK
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Month
1
2
3
4
5
6
7
8
9
10
11
12
Year
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Please upload a clear photo of the entire test casette encompassing our unique QR code on it after you have taken the test. Unclear photos will be rejected and a certificate will not be issued.
*
Max. file size: 128 MB.
No need to upload a photo of your ID/ Passport.
Purpose of Test
*
Post-travel (Day 2)
Vaccination status
*
Yes
No
I prefer not to answer
Any other details you would like included on form:
Only required if using test for Day 2 tests
*
Confirmation that the test complies, and was undertaken in accordance, with the requirements applicable under the International Travel and Operator Liability Regulations
*
Confirmation that the test is a lateral flow device test undertaken by an eligible traveller
*
Where the test provider did not administer sample collection services (that is, take the swab), the date and time that the test provider received evidence of the test result
*
Confirmation that the test is a lateral flow device test undertaken by an eligible traveller
Δ
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