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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
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Last Name
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Email Address
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Mobile Number
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Date of Birth (DD/MM/YYYY)
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PPS Number
*
Are you a patient of the Practice?
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Yes
No
Positive Antigen Test
*
Yes
No
Tick if applicable to you
Healthcare Worker
Underlying Conditions
Are you Symptomatic?
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Yes
No
If you are symptomatic, please describe your symptoms.
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