COVID-19 Antigen Test
19 Kensington High Street, London, W8 5NP
Patient Information
Patient name
*
Mattia
Last Name
Date of Birth
*
-
Day
-
Month
Year
Gender
*
Male
Female
Passport Number
*
As shown on your passport
Contact Number
*
Please enter a valid phone number
Email
*
example@example.com
Appointment
Please choose the date and time of your antigen test.
Select Appointment Slot
*
Consent
By continuing with your booking you understand that you must not attend if you're presenting any COVID-19 symptoms including a temperature above 37.8°C, a persistent cough or have difficulties breathing. You may attend the centre once your symptoms have resolved and/or you have completed self-isolation for 10 days.
*
I, the above-mentioned patient, I hereby agree and confirm that the information provided in this request form is true and complete. I authorise Prince Pharmacy to forward the related information to governmental agencies if required to do so. I agree to self-isolate until my test is completed. If I test positive, I adhere to the current government guidelines relating to the COVID-19.
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Certificate Fields
Test Date & Time
-
Day
-
Month
Year
Date
Hour Minutes
Report Issued
-
Day
-
Month
Year
Date
Hour Minutes
SARS CoV-2 RNA
POSITIVE
NEGATIVE
DETECTION OF SARS CoV-2 RNA
NOT DETECTED
DETECTED
STATED SYMPTOMS ASSOCIATED WITH COVID-19
NONE REPORTED
Other
Fit-to-Fly
Yes
No
Certificate Number
QRCAL
Should be Empty: