NEW Covid Form

Fusion Radiology Ltd - Covid-19 PCR Test (Fit to Fly)
Swab PCR Test Request Form
If you require a travel certificate for a flight, we recommend you order your test well ahead of time. Results can be delivered upto 24 - 36 hrs after receiving swab sample. It is your responsibility to check the travel requirements of the airline and country you are travelling to and to ensure your results are recieved within the time frame required by the airline and country.
First Name*
Surname*
Date of Birth (DD/MM/YY)*
Male or Female*
Address *
(Full address)
Postcode*
Swab Taken Date: *
(Please enter preferred date you would like your swab taken)
Time:*

(Exact hour and minutes you would prefer to be seen) Minutes

AM/PM Option
Contact Number*
(Please enter a valid phone number to be contacted on)
Email *
(An email that you would like your results to be sent to)
Passport No.*
(Located in your passport)
Which Country will you be flying to?*
(Please specify which country you will be flying to)
Please input the date that you will be flying - Note: You must allow at least 48 hours before a flight for a swab to be taken*
Flight time: Input minutes and hour*
Which Test centre would you like to give PCR swab sample ?*
I the patient/on behalf of the patient give consent (permission) by completing this form, for Fusion Radiology to follow up, collect and process the swab test results which will be reported back to me.
Signature: *

Clear
A GMC certificate will be issued for you by an NHS registered clinician.

The lab used is ISO: 15189 and UKAS approved.

My Products

COVID-19 PCR Test (Fit 2 Fly)

£70.00

Total

£0.00

Credit /Debit Card

Thank you. Your details are with us we will get back to you as soon as possible.
Should be Empty:

Fusion Radiology Ltd - Covid-19 PCR Test (Fit to Fly)

Credit /Debit Card

Thank you. Your details are with us we will get back to you as soon as possible.