Covid-19 PCR Fit to Travel Registration Form

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 full Postal Address: *

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

4. Please enter your Date of Birth: *

	DD/MM/YYYY
DOB:

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 Contact Details: *

Telephone (Landline)
Mobile	*

8. Please enter your Email Address: *

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

Yes
No

10. Please tick to indicate which type of email communications you consent to receiving? *

Un-encrypted (non-secure)
Encrypted (secure – you will need to go through an online process to access the email / attachments)

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

Yes
No

12. If you require your Passport Number to be on your certificate please enter it here:

13. Please enter details for your Next of Kin:

Name
Relationship
Telephone

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

Click to View Terms and Conditions

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

I agree

15. Please click on the link below to view our Privacy Policy:
Privacy Policy
Please tick the box to confirm that you have read and consent to our Privacy Policy *

I Consent

Powered by SmartSurvey