COVID-19 Travel Certification Form

COVID-19 Travel Certification Form
COVID-19 Test Type *

RAT PCR
Date of PCR Test *
Pathology Lab
Current supported labs
Have you received a confirmed Negative test result?

Yes No
Once we receive your form we will contact you to arrange a supervised RAT Test.
You must receive a PCR test result before applying for a Travel Certificate.

Please visit a local COVID-19 collection facility to get a PCR test done.

Re-visit this form once you have received your Negative test result.
Full Name (exactly per your Passport) *

First Name Middle Name Last Name
Birth Date *

Day Month Year
Gender *
Passport Number *
Destination
Airline
Departure Date & Time
Address *

Street Address

Street Address Line 2

City State

Postal Code Country
Phone Number *
E-mail *
example@example.com
*

I confirm that I have checked all the requirements and selected the correct COVID-19 test for my travel destination. (If you are not sure please check with the airlines and the embassy of your travel destination before booking a COVID-19 test/certification.)
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