Kit registration – Covid-19 | Affinity Biomarker Labs

Please fill in ALL fields that are relevant to your test, failure to do so may result in a delay in receiving your test results.

Name *

First

Last

Date of birth (dd/mm/yyyy) *

Gender *

Date of collection *

Time of collection (hh:mm) *

Passport No. or ID Reference Number *

Passport expiry date (mm/yy) *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Ethnicity *

Email *

Phone number *

NHS number (if known/applicable)

Self-isolation address same as current address?

Self-isolation address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Covid-19 vaccination status

Date of arrival in the UK (dd/mm/yyyy)

The date on which you last departed from or transited through a country or territory outside the common travel area (dd/mm/yyyy)

The country/territory where you arrived from into the UK

Country/Territory you transited through as part of that journey

Method of Transportation

Flight/Train/Vessel/Coach Number

Any other Country or territory you transited through as part of that journey

Country 2

Country 3