COVID FORM - MOBILE

1
Which best describes your test kit?* This field is required.
An individual test kit purchased through AssuredScreening.com
An individual test kit purchased through another company/reseller
2
What type of test specimen are you taking?* This field is required.
SWAB TEST - RT-qPCR Test for COVID-19
BLOOD TEST - Antibody Test for COVID-19
3
Are you taking this test for travel purposes?Click 'Yes' if you require a COVID-free travel certificate
YESNO
4
Does your device have a camera?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.
YESNO
5
Sample Specimen ID Number* This field is required.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.
6
Sample Specimen ID Number* This field is required.The Sample Specimen ID Number consists of 3 letters and 4 or 5 numbers (eg. ABC12345). This can be found at the bottom of the barcode label on the sample specimen tube. 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.
7
Re-enter Sample Specimen ID Number* This field is required.
8
Sample Date* This field is required.When will you take the sample specimen?
Date
Day
Month
Year
9
Sample TimeWhat time will you take the sample on the sample date?
07
00
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Hour
45
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Minutes
10
Postage Date* This field is required.When will you be posting or dropping off the the sample specimen?
Date
Day
Month
Year
11
Enter the Royal Mail Barcode Number on the Special Delivery/Tracked Returns bagThis allows us to track your sample back into our laboratory. Ignore if you are not sending via our prepaid Royal Mail/ Post Office Returns service.
12
Name* This field is required.Please enter the name of the person taking the test.
First Name
Last Name
13
Address* This field is required.Please enter your address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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
Country
14
Date of Birth* This field is required.Please enter your date of Birth.
Date
Day
Month
Year
15
Passport NumberSome 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.
16
Email* This field is required.Please enter your email address. You will be required to verify you email address as results are send via email.
example@example.com
Confirm Email
17
Phone Number* This field is required.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.
Area Code
Phone Number
18
Are you currently displaying any COVID-19 symptoms?* This field is required.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).
YESNO
19
Terms and Conditions* This field is required.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 24-48 hours of receipt of sample specimen however is not liable in any way should testing go beyond this time for any reason. All test results are indications and not guarantees.
20
Privacy and GDPR* This field is required.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.
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