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PCR Test Referral Request
When to get a PCR Test – Click Here
Use this form to request a PCR Test Referral.
First Name
*
Last Name
*
Email Address
*
Mobile Number
*
Date of Birth (DD/MM/YYYY)
*
PPS Number
*
Are you a patient of the Practice?
*
Yes
No
Positive Antigen Test
*
Yes
No
Tick if applicable to you
Healthcare Worker
Underlying Conditions
Are you Symptomatic?
*
Yes
No
If you are symptomatic, please describe your symptoms.
Thank you for your request. It has been sent and we will be in touch.
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