You can always press Enter⏎ to continue
COVID SUBMISSION FORM
All test kits must be successfully and accurately registered before sending to the laboratory. Any incorrect information entered in this form may result in delay or non-issue of results. After submission, mistakes can not be rectified.
  • 1
    Why are you taking your COVID PCR Test?
    Press
    Enter
  • 2
    Click 'Yes' if you require a COVID-free travel certificate
    Press
    Enter
  • 3
    Your camera can be used to scan the Sample Specimen ID number. The Sample Specimen ID number is a barcode label found either on the sample specimen tube or in a separate sheet of 3 or 4 labels. This is the most accurate way to register your kit. If your device is unable to take a picture, please click NO and enter this manually.
    Press
    Enter
  • 4
    The Sample Specimen ID barcode is your unique test reference and consists of 3 letters and 4 or 5 numbers (eg. ABC1234 or ABC12345). It can be found on the barcode strips or already on the sample specimen tube. Does your barcode contain 4 or 5 numbers?
    Press
    Enter
  • 5
    The Sample Specimen ID Number consists of 3 letters and 4 or 5 numbers (eg. ABC1234). Please scan the barcode located on the sample specimen tube via your mobile device or webcam. If you are unable to scan a barcode, please click back and select 'No'. The Sample Specimen ID number is a barcode label found either on the sample specimen tube or in a separate sheet of 3 or 4 labels. THIS IS NOT THE QR CODE - DO NOT SCAN A QR CODE OR THE TEST WILL NOT BE REGISTERED.
    Press
    Enter
  • 6
    Please enter your unique test sample specimen ID barcode. The barcode consists of 3 letters and 4 numbers eg ABC1234. Ensure that this is correct as incorrectly entered numbers will delay sample processing. If your barcode is too long, click previous and select 5. DO NOT REMOVE DIGITS FROM THE BARCODE AS YOUR TEST WON'T BE PROCESSED.
    Press
    Enter
  • 7
    Please enter your unique test sample specimen ID barcode. The barcode consists of 3 letters and 4 or 5 numbers eg ABC12345. Ensure that this is correct as incorrectly entered numbers will delay sample processing.
    Press
    Enter
  • 8
    When will you take the sample specimen?
    Pick a Date
    Press
    Enter
  • 9
    What time will you take the sample on the sample date?
    11
    • 00
    • 01
    • 02
    • 03
    • 04
    • 05
    • 06
    • 07
    • 08
    • 09
    • 10
    • 11
    • 12
    • 13
    • 14
    • 15
    • 16
    • 17
    • 18
    • 19
    • 20
    • 21
    • 22
    • 23
    27
    • 00
    • 01
    • 02
    • 03
    • 04
    • 05
    • 06
    • 07
    • 08
    • 09
    • 10
    • 11
    • 12
    • 13
    • 14
    • 15
    • 16
    • 17
    • 18
    • 19
    • 20
    • 21
    • 22
    • 23
    • 24
    • 25
    • 26
    • 27
    • 28
    • 29
    • 30
    • 31
    • 32
    • 33
    • 34
    • 35
    • 36
    • 37
    • 38
    • 39
    • 40
    • 41
    • 42
    • 43
    • 44
    • 45
    • 46
    • 47
    • 48
    • 49
    • 50
    • 51
    • 52
    • 53
    • 54
    • 55
    • 56
    • 57
    • 58
    • 59
    Press
    Enter
  • 10
    When will you be posting or dropping off the the sample specimen?
    Pick a Date
    Press
    Enter
  • 11
    Where possible, we recommend returning to one of our drop box locations - see www.assuredscreening.com/returns
    Press
    Enter
  • 12
    This allows us to track your sample back into our laboratory. If using the Royal Mail pre-paid envelope, please enter the barcode number.
    Press
    Enter
  • 13
    This allows us to track your sample back into our laboratory.
    Press
    Enter
  • 14
    Please enter the location of the Dropbox used. Visit assuredscreening.com/returns for more details of our locations
    Press
    Enter
  • 15
    Please enter the name of the person taking the test.
    Press
    Enter
  • 16
    Press
    Enter
  • 17
    Please enter your address
    Please Select
    • Please Select
    • United States
    • Afghanistan
    • Albania
    • Algeria
    • American Samoa
    • Andorra
    • Angola
    • Anguilla
    • Antigua and Barbuda
    • Argentina
    • Armenia
    • Aruba
    • Australia
    • Austria
    • Azerbaijan
    • The Bahamas
    • Bahrain
    • Bangladesh
    • Barbados
    • Belarus
    • Belgium
    • Belize
    • Benin
    • Bermuda
    • Bhutan
    • Bolivia
    • Bosnia and Herzegovina
    • Botswana
    • Brazil
    • Brunei
    • Bulgaria
    • Burkina Faso
    • Burundi
    • Cambodia
    • Cameroon
    • Canada
    • Cape Verde
    • Cayman Islands
    • Central African Republic
    • Chad
    • Chile
    • China
    • Christmas Island
    • Cocos (Keeling) Islands
    • Colombia
    • Comoros
    • Congo
    • Cook Islands
    • Costa Rica
    • Cote d'Ivoire
    • Croatia
    • Cuba
    • Curacao
    • Cyprus
    • Czech Republic
    • Democratic Republic of the Congo
    • Denmark
    • Djibouti
    • Dominica
    • Dominican Republic
    • Ecuador
    • Egypt
    • El Salvador
    • Equatorial Guinea
    • Eritrea
    • Estonia
    • Ethiopia
    • Falkland Islands
    • Faroe Islands
    • Fiji
    • Finland
    • France
    • French Polynesia
    • Gabon
    • The Gambia
    • Georgia
    • Germany
    • Ghana
    • Gibraltar
    • Greece
    • Greenland
    • Grenada
    • Guadeloupe
    • Guam
    • Guatemala
    • Guernsey
    • Guinea
    • Guinea-Bissau
    • Guyana
    • Haiti
    • Honduras
    • Hong Kong
    • Hungary
    • Iceland
    • India
    • Indonesia
    • Iran
    • Iraq
    • Ireland
    • Israel
    • Italy
    • Jamaica
    • Japan
    • Jersey
    • Jordan
    • Kazakhstan
    • Kenya
    • Kiribati
    • North Korea
    • South Korea
    • Kosovo
    • Kuwait
    • Kyrgyzstan
    • Laos
    • Latvia
    • Lebanon
    • Lesotho
    • Liberia
    • Libya
    • Liechtenstein
    • Lithuania
    • Luxembourg
    • Macau
    • Macedonia
    • Madagascar
    • Malawi
    • Malaysia
    • Maldives
    • Mali
    • Malta
    • Marshall Islands
    • Martinique
    • Mauritania
    • Mauritius
    • Mayotte
    • Mexico
    • Micronesia
    • Moldova
    • Monaco
    • Mongolia
    • Montenegro
    • Montserrat
    • Morocco
    • Mozambique
    • Myanmar
    • Nagorno-Karabakh
    • Namibia
    • Nauru
    • Nepal
    • Netherlands
    • Netherlands Antilles
    • New Caledonia
    • New Zealand
    • Nicaragua
    • Niger
    • Nigeria
    • Niue
    • Norfolk Island
    • Turkish Republic of Northern Cyprus
    • Northern Mariana
    • Norway
    • Oman
    • Pakistan
    • Palau
    • Palestine
    • Panama
    • Papua New Guinea
    • Paraguay
    • Peru
    • Philippines
    • Pitcairn Islands
    • Poland
    • Portugal
    • Puerto Rico
    • Qatar
    • Republic of the Congo
    • Romania
    • Russia
    • Rwanda
    • Saint Barthelemy
    • Saint Helena
    • Saint Kitts and Nevis
    • Saint Lucia
    • Saint Martin
    • Saint Pierre and Miquelon
    • Saint Vincent and the Grenadines
    • Samoa
    • San Marino
    • Sao Tome and Principe
    • Saudi Arabia
    • Senegal
    • Serbia
    • Seychelles
    • Sierra Leone
    • Singapore
    • Slovakia
    • Slovenia
    • Solomon Islands
    • Somalia
    • Somaliland
    • South Africa
    • South Ossetia
    • South Sudan
    • Spain
    • Sri Lanka
    • Sudan
    • Suriname
    • Svalbard
    • eSwatini
    • Sweden
    • Switzerland
    • Syria
    • Taiwan
    • Tajikistan
    • Tanzania
    • Thailand
    • Timor-Leste
    • Togo
    • Tokelau
    • Tonga
    • Transnistria Pridnestrovie
    • Trinidad and Tobago
    • Tristan da Cunha
    • Tunisia
    • Turkey
    • Turkmenistan
    • Turks and Caicos Islands
    • Tuvalu
    • Uganda
    • Ukraine
    • United Arab Emirates
    • United Kingdom
    • Uruguay
    • Uzbekistan
    • Vanuatu
    • Vatican City
    • Venezuela
    • Vietnam
    • British Virgin Islands
    • Isle of Man
    • US Virgin Islands
    • Wallis and Futuna
    • Western Sahara
    • Yemen
    • Zambia
    • Zimbabwe
    • Other
    Press
    Enter
  • 18
    Please enter your date of Birth.
    Pick a Date
    Press
    Enter
  • 19
    Some destinations require passport number details to be listed on the COVID-free certificate. Please enter this is you would like this including, if not, leave blank.
    Press
    Enter
  • 20
    Please enter your destination Country if using for travel. This is used for research purposes only.
    Press
    Enter
  • 21
    Please enter your email address. You will be required to verify you email address as results are send via email.
    Press
    Enter
  • 22
    Please enter your phone number. We will only use this if we need to contact you about your test and are unable to get an email response.
    Press
    Enter
  • 23
    Symptoms include continuous cough, fever or loss of smell/taste. If YES, please isolate and arrange for a further diagnostic test/medical assistance via the NHS (UK) or HSE (ROI).
    Press
    Enter
  • 24
    ​Assured Screening, a trading name of Honeyman Group Ltd provides screening on a best endeavours basis. Testing provides a historic, momentary result. An individuals health status may have changed since the test was carried out. All results are based on the sample specimen provided and do not take into account any clinical assessment or patient diagnosis. It is therefore imperative to closely follow sampling instructions and ensure a good quality of specimen collection. Specimens of poor quality may fail processing or provide inconclusive results on test instruments. These will not be refunded. In such cases it is advised that the individual purchase a new test kit for a retest. Assured Screening prides itself on speedy sample turnaround and aims to provide results within 48 hours of receipt of sample specimen (or as per product turnaround aim) however is not liable in any way should testing go beyond this time for any reason. Assured Screening is not responsible for any postal delays caused by Royal Mail or other third party. It is the responsibility of the customer to ensure that the test and service is suitable to their needs. It is agreed that once this form has been submitted that the test will be non-refundable and will be processed upon receipt at the laboratory. Any false or incorrect information provided within this submission may result in a delay to issuing of results. All test results are indications and not guarantees.
    Press
    Enter
  • 25
    Transparency and Control are inherently our watchwords at Assured Screening, as we help assure compliance in highly regulated industries including Pharmaceutical, Healthcare and Medical. Assured Screening complies with GDPR regulations. Data is electronically stored to allow any communication necessary for the performance of a contract between our company and the individual to provide testing services. Data is stored securely and not on removable drives. Data maybe held for a period of 7 years as part of our traceable quality system. This is in the event we may need to contact you regarding your result in the future. Assured Screening minimises the number of staff with access to personal data. You agree that personal data could be shared with the following third parties as part of the COVID response or during the course of a laboratory inspection/investigation - Public Health England, National Health Service, The Department of Health and Social Care, United Kingdom Accreditation Service. If you have purchased a test through one of our clinical partners, you also agree that we can provide report your test result to them. Sample Specimens are discarded and incinerated after issuing of approved results.
    Press
    Enter
  • 26
    Press
    Enter
  • 27
    Press
    Enter
  • Should be Empty:
COVID SUBMISSION FORM
[Edit]
Question Label
1 of 27See AllGo Back
close