SERVICE EXCELLENCE THROUGH SCIENCE
Sign In
Activate
0800 193 7999
HOME
SHOP
SERVICES
Fit to Fly PCR Testing
Workplace Testing
Verified by Video
Government Testing
INFO
Blog
Knowledge Hub
Covid Variants
ABOUT US
HOME
SHOP
SERVICES
Fit to Fly PCR Testing
Pre-departure Lateral Flow Testing
Day 2 PCR Testing
Workplace Testing
Verified by Video
Government Testing
Day 2 Lateral Flow Testing
Test To Release
INFO
Blog
Knowledge Hub
Covid Variants
ABOUT US
Kit Activation Form
Sample Barcode
First Name
Last Name
Have you already completed a travel information form as part of the online booking process?
(Please select no and complete the following section if you have not provided this information for the individual named above when booking your test)
Yes
No
Date Of Birth
(DD/MM/YYYY)
Sampling Date
(DD/MM/YYYY)
Sampling Time
00:00
01:00
02:00
03:00
04:00
05:00
06:00
07:00
08:00
09:00
10:00
11:00
12:00
13:00
14:00
15:00
16:00
17:00
18:00
19:00
20:00
21:00
22:00
23:00
Additional Information Required for the UK Health Security Agency - please complete as fully as possible
Address
Post code
Email
Phone
VaccinationStatus
Not vaccinated
Single vaccination
Double vaccination
Passport Number
(Mandatory for F2F certificates)
NHS Number
Ethnicity
ANY OTHER ETHNIC CATEGORY
ANY OTHER MIXED GROUP
BANGLADESHI
BLACK - AFRICAN
BLACK - CARIBBEAN
BLACK - OTHER
CHINESE
INDIAN
ISC - UNSPECIFIED
OTHER / MIXED
PAKISTANI
UNKNOWN
WHITE
WHITE AND ASIAN
WHITE AND BLACK AFRICAN
WHITE AND BLACK CARIBBEAN
WHITE BRITISH
WHITE IRISH
WHITE OTHER
Gender
Female
Male
I'd rather not say
Consent
I consent to Cellmark carrying out a COVID-19 test on the donor’s sample (if the donor is a child I confirm that I have the legal authority to give consent).
I consent to the donor’s personal details being stored and processed by Cellmark (please see Cellmark’s privacy policy for data retention timeframes).
I consent to the donor’s test result and personal details being reported to the UK Health Security Agency, in compliance with public health legislation.
In the event of a positive result I understand my sample may be passed to Cellmark's sequencing partner for further analysis as detailed in the testing Terms and Conditions
Mandatory field