Fit to Fly Consent Form

Title *

Name *

First Name Last Name

Date of Birth *

Month Day Year

Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Passport Number *

NHS Number *

Email *

example@example.com

Mobile number *

Destination Country *

Departure date & time *

Arrival date & time *

General Information

Please fill in this form and the Covid19 questionnaire shortly before your appointment for sample collection (at the very earliest 12 hours beforehand In order to save the most time, we advise that you complete the form, date, sign, declare the time (to the nearest minute) that you have done so, and then scan and return to info@shantyspharmacy.com. Please complete ALL fields, as this will help to avoid delays in processing your sample. We advise that you bring your passport and the exact date and time (both of departure and landing) of your flight to the appointment.

Data Sharing

Your data will be stored at Shantys Pharmacy, and shared with our lab partner (Everything Genetic Ltd), in line with our GDPR policy, so that they can process your lab result. Your data will not be shared outside Shantys Pharmacy or Everything Genetic Ltd, unless you receive a positive result, inwhich case we are obliged to inform NHS Test and Trace by law.

Country Requirements and Timings

The requirements and timings of Fit to Fly Certificates and your negative test vary for each country. The most

up do date requirements can be found at https://www.gov.uk/foreign-travel-advice. If you submit your swab

sample before 4:30pm, we will be able to return the test result and certificate to youby 6pm the next day. Please check your destination country's requirements, ensure that your timings for the test are accurate, and then book in. If you are still unsure prior to booking, then please come inor call us on 02072472140 and we will help you to decide the timing of your test.

Please tick the correct answer to the questions below before providing your swab sample. *

	Yes	No
Have you tested positive for or has symptoms of Covid19 in the last 90 days?
Have you or anyone in your household/support bubble experienced a new dry persistent continuous cough in the last 10 days?
Did you or anyone in your household/support bubble have a high fever 37.8c and above in the last 10 days?
Did you or anyone in your household/support bubble suffer a loss of taste or smell in the last 10 days
Are you or anyone in your household/support bubble currently waiting for a COVID test result?
Have you been notified by the NHS Test and Trace service that you've been in contact with a person with COVID in the last 10 days?
Have you entered the UK from a foreign country in the last 10 days
Did you or anyone in your household/support bubble experience shortness of breath or difficulties breathing in the last 10 days?
Did you or anyone in your household/support bubble suffer from diarrhoea or stomach ache in the last 10 days?
Did you, anyone in your household/support bubble experience a headache and/or fatigue in the last 10 days?
Did you, anyone in your household/support bubble have/had any flu symptoms in the last 10 days?

I consent to Shantys Pharmacy and Everything Genetic Ltd storing and using my personal data in linewith their

GDPR policies, and forwarding my swab sample for my Covid19 PCR test to Everything Genetic Ltd's laboratory.I understand that:

In the event that my test result is positive, NHS Test and Trace will be informed and I will need isolate at home in line with Government advice for 10 days from the date of my test.
Certain circumstances outside of the control of Shantys Pharmacy might lead to a test resultdelay, in which case I will be entitled to a refund of the cost of my test, but neither Shantys Pharmacy nor Everything Genetic Ltd will accept liability for any other costs incurred.
It is up to me to provide accurate details with respect to my identity, personal information, departure/landing times and travel destination, and that Shantys Pharmacy will not accept liability for any losses arising from incorrect disclosure of information on my part.
I have now been given all of the information that I need with respect to the Covid19 testing

Other Services

Please tick this box if you would NOT like to receive marketing material and reminders by email or text for other services.

Signed *

Clear

Date

Time *

Print name *

(Please state relationship to patient if you are signing on their behalf):

Fit to Fly Patient Consent Form

COVID19 QUESTIONNAIRE