COVID-19 Online Booking Form

COVID-19 Online Booking Form

Please complete the form to book your COVID-19 test at our London Clinic (ProBack Clinic), or Home Visit. We will contact you to confirm your appointment shortly. For more information, visit our website www.10laser.co.uk (Payment collected onsite)
If you are currently suffering severe symptoms such as shortness of breath, loss of speech or movement or high fever please contact your GP immediately.
Full Name

First NameLast Name
Date of Birth

DayMonthYear
Date
Phone Number
Format: 00000000000.
E-mail
Address

Street Address

Street Address Line 2

CityCounty

Post Code
Doctor Home Visit – *London Zone 1– 4 only* (+ £50):
Appointment date preferred (to be confirmed)

DayMonthYear
Date
Ethnic Background

Other
Due to the new Covid-19 social distance regulations required by the government, we are currently taking bookings (carrying out one to one tests). Open from Monday to Saturday, located at PROBACK Clinic Flat 4, Evelyn Mansions, Carlisle Place, Westminster, London, SW1P 1NH.
Please complete your preferred estimated Date/Time for your appointment (the clinic will call you to confirm)

MonthDayYear
Please complete the questionnaire below as accurate as possible prior to your appointment.
Are you currently suffering from any of the following symptoms: Fever, Dry Cough, Breathing Difficulty, Tiredness or Loss of taste or smell?
Have you suffered with any of the Covid-19 symptoms in the last 14 days: Fever, Dry Cough, Breathing Difficulty, Tiredness or Loss of taste or smell?
Have you been in contact with anyone in the last 14 days who has contracted Covid-19?
Have you recently been tested for Covid-19?
If Yes please select test type and date of test:
DayMonthYear
Date
Notes:
Should be Empty: