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
White (English, Welsh, Irish, Scottish, British)White OtherBlack/African/Caribbean/Black BritishAsian / Indian/Pakistani/Bangladeshi/Asian BritishAny other Mixed / Multiple ethnic backgroundArabicOther
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.
YesNo
YesNo
YesNo
YesNo
If Yes please select test type and date of test:
DayMonthYear
Date
Notes:
Should be Empty: