BOOKING REFERENCE FORM
All sections below are mandatory and a legal requirement by Public Health England. You must fill in each section to be issued a booking reference number.
Number of Passengers
*
Please Select
1
2
3
4
Passenger 1 - Full Name As Stated on Passport
*
First Name
Middle Name
Last Name
Passenger 1 Email
*
example@example.com
Passenger 1 - Date of Birth
*
-
Day
-
Month
Year
Passenger 1 - Gender (as specified on your passport)
*
Please Select
Male
Female
Other
Passenger 1 - Passport Number
*
Passenger 1 - Ethnicity
*
Please Select
White- English, Welsh, Scottish, Northern Irish or White - British
White - Irish
White - Gypsy or Irish Traveller
Any other White background
White and Black Caribbean
White and Black African
White and Asian
Any other Mixed or Multiple ethnic background
Indian
Pakistani
Bangladeshi
Chinese
Any other Asian background
African
Caribbean
Any other Black, African or Caribbean background
Arab
Any other ethnic group
Passenger 1 - Vaccination Status
*
Please Select
Pfizer
Moderna
Oxford/Astrazeneca
Other
Not Vaccinated
Passenger 2 - Full Name As Stated on Passport
*
First Name
Middle Name
Last Name
Passenger 2 Email
*
example@example.com
Passenger 2 - Date of Birth
*
-
Day
-
Month
Year
Date
Passenger 2 - Gender (as specified on your passport)
*
Please Select
Male
Female
Other
Passenger 2 - Passport Number
*
Passenger 2 - Ethnicity
*
Please Select
White- English, Welsh, Scottish, Northern Irish or White - British
White - Irish
White - Gypsy or Irish Traveller
Any other White background
White and Black Caribbean
White and Black African
White and Asian
Any other Mixed or Multiple ethnic background
Indian
Pakistani
Bangladeshi
Chinese
Any other Asian background
African
Caribbean
Any other Black, African or Caribbean background
Arab
Any other ethnic group
Passenger 2 - Vaccination Status
*
Please Select
Pfizer
Moderna
Oxford/Astrazeneca
Other
Not Vaccinated
Passenger 3 - Full Name As Stated on Passport
*
First Name
Middle Name
Last Name
Passenger 3 Email
*
example@example.com
Passenger 3 - Date of Birth
*
-
Day
-
Month
Year
Date
Passenger 3 - Gender (as specified on your passport)
*
Please Select
Male
Female
Other
Passenger 3 - Passport Number
*
Passenger 3 - Ethnicity
*
Please Select
White- English, Welsh, Scottish, Northern Irish or White - British
White - Irish
White - Gypsy or Irish Traveller
Any other White background
White and Black Caribbean
White and Black African
White and Asian
Any other Mixed or Multiple ethnic background
Indian
Pakistani
Bangladeshi
Chinese
Any other Asian background
African
Caribbean
Any other Black, African or Caribbean background
Arab
Any other ethnic group
Passenger 3 - Vaccination Status
*
Please Select
Pfizer
Moderna
Oxford/Astrazeneca
Other
Not Vaccinated
Passenger 4 - Full Name As Stated on Passport
*
First Name
Middle Name
Last Name
Passenger 4 Email
*
example@example.com
Passenger 4 - Date of Birth
*
-
Day
-
Month
Year
Date
Passenger 4 - Gender (as specified on your passport)
*
Please Select
Male
Female
Other
Passenger 4 - Passport Number
*
Passenger 4 - Ethnicity
*
Please Select
White- English, Welsh, Scottish, Northern Irish or White - British
White - Irish
White - Gypsy or Irish Traveller
Any other White background
White and Black Caribbean
White and Black African
White and Asian
Any other Mixed or Multiple ethnic background
Indian
Pakistani
Bangladeshi
Chinese
Any other Asian background
African
Caribbean
Any other Black, African or Caribbean background
Arab
Any other ethnic group
Passenger 4 - Vaccination Status
*
Please Select
Pfizer
Moderna
Oxford/Astrazeneca
Other
Not Vaccinated
Flying From
*
Flying To
*
Flight / Vessel Number
*
Phone Number
*
-
Area Code
Phone Number
Departure Date
*
-
Day
-
Month
Year
Date
Arrival Date
*
-
Day
-
Month
Year
Date
Address While Residing In The UK
*
Street Address
Street Address Line 2
City
County
Postal / Zip Code
I consent to having (med)24 store my information for legal reasons. If your test returns a positive result (this applies to swabs only and not antibody testing), we will be required by law to share the following additional information to Public Health England: your contact phone number, your email address, your self-isolation address.
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