Day 2 International Arrivals

1. Please enter your Full Name including any middle names: *

First Name	*
Middle Name
Surname	*

2. Please indicate your gender: *

Male
Female

3. Please enter your Date of Birth: *

	DD/MM/YYYY
DOB:

4. Please enter your NHS number (if known):

6. Please state below the date and type of any Covid-19 vaccines you have received to date.
(Please leave blank if you have not yet received your first dose of a Covid-19 vaccine)

1st Vaccine Dose (Please state date and type)
2nd Vaccine Dose (Please state date and type)

7. Please enter your Passport or ID card number: *

8. Please enter your full Postal Address: *

First Line of Address	*
Second Line of Address
Town/City	*
Postcode	*

9. Please enter the address where you will be isolating until you receive your Day 2 result: *

First Line of Address	*
Second Line of Address
Town/City	*
Postcode	*

10. Please enter the date of your arrival to the UK:

	DD/MM/YYYY

11. Please state below any countries that you transited through while travelling back to the UK? (Please write NONE if not applicable) *

12. Please state the time of your arrival in the UK?

	HH	MM

13. Which country or territory were you travelling from when you arrived back to the UK? *

14. Please state the date on which you departed from (or last transited through) a country outside of the UK? *

	DD/MM/YYYY

15. Please state your coach number, flight number or vessel name (as appropriate): *

16. Please enter your Email Address: *

17. Please enter your Contact Details: *

Telephone (Landline)
Mobile	*

18. Do you give your Consent for our service to communicate with you by email? *

Yes
No

19. Please tick to indicate which type of email communication you consent to receiving?

Un-encrypted (Non-secure)
Encrypted (Secure - You will need to go through an online process to access the email / attachments)

20. Do you give your Consent for our service to communicate with you by SMS? *

Yes
No

21. Our Terms and Conditions can be viewed by clicking on the link below:

Click to view Terms and Conditions

Please tick the box below to confirm that you have read and agree to our Terms and Conditions:

I Agree

22. Please click on the link below to view our Privacy Policy:

Privacy Policy

Please tick the box below to confirm that you have read and consent to our Privacy Policy:

I Consent

23. As part of the our Covid-19 testing service we are legally obliged, on request, to share data submitted on this form with Public Health England or, if approached, with the Police (in exceptional circumstances where they need to confirm a quarantine period). Please tick the box below to indicate you understand this and consent:

I Consent

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