Lateral Flow Test Result Form

Your Info

First Name

Last Name

Date Of Birth

Passport Number

Phone

Your test details

Sample Barcode

Test Date

Kit and device image

Example:

LFD Photo image 1

Close up image

Example:

LFD Photo Image 2

Both of your photographs must be clear and in focus. If the photographs you provide are unsuitable we will be not be able to provide you with your certificate and you will need to take another test.

Address (If different to when the test was ordered)

Address 1

Address 2

Town/City

Postcode

By ticking this checkbox:

• I consent to my personal details being stored and processed by Cellmark (please see Cellmark’s privacy policy for data retention timeframes).
• I consent to the test result and personal details being reported to the UK Health Security Agency (UKHSA) in compliance with public health legislation.