COVID-19 Swab Request
Phone Number (Ideally Mobile)
What is your occupation?
What symptoms do you have?
Shortness of breath
Loss of sense of smell
How many days have you had the above symptoms for?
Have you travelled overseas or have had contact with a confirmed/probable case in the past 14 days?
Travelled Overseas in the past 14 days
Contact with a confirmed/probable case
Are you a healthcare worker/essential worker? Do you reside in a communal environment?
Reside in a communal environment e.g aged residential care, prisons, large extended family, university hall, hostel or shelter
Do you feel you need to be assessed by the doctor?
Yes - I need to be seen face to face
No - I would just like a swab
We will get back to you shortly with an appointment time for the swab.
Should be Empty:
Now create your own JotForm - It's free!
Create your own JotForm