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Covid Day 2 & 8 Tests - NHL - data collection form
Please fill out all fields completely to prevent any delays in processing your purchase. Please fill out a new form for each test package to be purchased. By completing this for I the undersigned acknowledge A Mann LTD T/A NHL Pharmacy is not held liable or responsible (inc financial) for any inaccuracy or delays experienced in obtaining results. I the customer must contact NHL to correct any inaccuracies or non receipt of certificated after the sample is taken. NHL pharmacy & Eyecare take no liability for losses financial or otherwise in connection with test results or difficulties boarding your flight.
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Email *
Forename *
Surname *
Sex *
Date of Birth *
MM
/
DD
/
YYYY
Ethnicity *
Required
Phone number *
Address *
Post Code *
Address you will be isolating at (if different to above) *
Name of Country you will be arriving from *
Name of country travelling to *
Flight number/vessel name/coach number *
Date of departure *
MM
/
DD
/
YYYY
Date of arrival in the UK *
MM
/
DD
/
YYYY
Passport number *
Passeneger Locator reference number (test to release) type unknown if not known
Vaccination status *
Required
Package Purchased (Please tick relevant) *
Required
Date of Test *
MM
/
DD
/
YYYY
Happy for us to share details with Lab, NHS and our services for the future *
Required
A copy of your responses will be emailed to the address you provided.
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