Lateral Flow Form - EffectDoctors

First Name *

Last Name *

Date of birth *

Sex *

Ethnicity *

Email *

Address Where you will be staying *

City/Town

Postcode *

Country

NHS Number

Mobile Phone Number

Do you have any COVID-19 symptoms? * I declare I have NO COVID-19 symptoms I declare I HAVE symptoms of COVID-19

My test was * NEGATIVE for Covid POSITIVE for Covid

Please upload a clear photo of the entire test casette encompassing our unique QR code on it after you have taken the test. Unclear photos will be rejected and a certificate will not be issued. *

DO NOT upload any personal identifiable information. E.g Passport, drivers license, etc.

Date of self test *

Date

Time of self test *

hh:mm

Purpose of Test *

Passport number

Passport Country of Issue