Patient Information Form

Schedule Date * : Time :

Time :

Date of Birth * :

First name * : (should match the name on your travel documents)

Surname * :

Gender * :
Male Female

Symptomatic * :
Yes No

Full address & Postcode * :

Contact No * :

Email Address *

Referring Partner :

Passport No : (Optional)

Comment :

If booking a Fit2fly, it is your own responsibility to ensure that you will have the right test date and time before traveling.
You must check with your travel provider if kids are required to have a Negative antibody test certificate before booking.

I confirm that I have read, understand and agree to the above policy and procedure.

Aarkri Ltd,
The Winning Box,
Office 2/3/4 /65, Second Floor,
Station Road, Hayes - UB3 4DX

In case you need our support or have some questions,
feel free to contact our team.