Patient Details

Symptoms

Tick as appropriat (required)
Fevers/Chills (fever usually above 38 degrees)Cough (can be dry or productive/chesty)Difficulty Breathing/Shortness of BreathSore throatRunny noseDiarrhoeaVomitingAches & PainsFatigueNo symptoms

Severity of Symptoms (required)

Travel

Have you travelled to an area affected by the Coronavirus or been in close contact with a confirmed case of Coronavirus? (this is not required for Covid-19 testing, however is useful information)

Recent Travel/Contact with confirmed Coronavirus case (required)
YesNo

Are you currently self isolating? (required)
YesNo

Anybody with respiratory symptoms of any kind is now advised to self-isolate.

Brief outline of your symptoms/concerns (required)

Please give a brief outline of your symptoms, when they started and your concern re testing. If you have any other symptoms not covered in the checklist above, please let us know here also.

Pre-existing medical conditions (required)

Please outline any significant pre-existing medical conditions that may put you in an at-risk category.

Consent to process your data (required)
Yes, you may process my data