Select Test—Please choose an option—Lateral Flow testDay 2
Your Barcode*
Booking Reference
Sample Taken Date
Sample Taken Time
Verified Sample Date
Verified Sample Time
Email*
Contact Number *
UK Address *
Isolation Address
Full Name *
Date Of Birth *
Ethnicity *—Please choose an option—White (English, Welsh, Scottish, Northern Irish, or British)White (Irish)White (Gypsy or Irish Traveller)White (Any other White background)Black (African)Black (Caribbean)Black (Any other Black, African, or Caribbean background)Asian (Indian)Asian (Pakistani)Asian (Bangladeshi)Asian (Chinese)Asian (Any other Asian background)Mixed (White and Black Caribbean)Mixed (White and Black African)Mixed (White and Asian)Mixed (Any other Mixed background)ArabAny other ethnic groupPrefer not to disclose
Gender *—Please choose an option—MaleFemalePrefer not to disclose
Passport/ID Number *
Vaccination Status *—Please choose an option—Fully VaccinatedPartially VaccinatedNot Vaccinated
Vaccine type*—Please choose an option—Oxford/AstraZenecaPfizer/BioNTechModernaJohnson & Johnson/JanssenNot vaccinated
Date of arrival in the UK *
Date Last Departure *
Mode of Travel *—Please choose an option—FlightTrainCoachOther
Flight Number
Country travelling from *—Please choose an option—AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanThe AzoresBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBolivia, Plurinational State ofBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsComorosCongoCongo, The Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHeard Island and McDonald IslandsHoly See (Vatican City State)HondurasHong KongHungaryIcelandIndiaIndonesiaIran, Islamic Republic ofIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMadeiraMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesia, Federated States ofMoldova, Republic ofMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPapua New GuineaParaguayPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussian FederationRwandaSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint Maarten (Dutch part)SlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyrian Arab RepublicTaiwanTajikistanTanzania, United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited StatesUnited States Minor Outlying IslandsUruguayUzbekistanVanuatuViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands
Date of last test before travelling (leave blank if not tested)
—Please choose an option—NegativePositive
