Covid Testing Form

Name*
First Last
Profession
Date
DD slash MM slash YYYY
Date of last PCR Covid test taken
DD slash MM slash YYYY
Result
- Positive
- Negative
Date current Lateral Flow Covid Test
DD slash MM slash YYYY
Date of next shift
DD slash MM slash YYYY
Site of next shift
Outcome from Lateral Flow Covid Test:
- Positive
- Negative
- Invalid
Upload a photo of the test result*
Max. file size: 1 GB.
Photo Date*
DD slash MM slash YYYY
Photo Time*

: HH

MM
Please self-isolate immediately

Contact the Clinic Co-ordinators here to cancel your shift

Request a PCR test via the NHS Test & Trace app/Government website

Contact Jake McGuie (Head of Nursing – Surgery) jmcguie@18weeksupport.com or Suzie Loader (Chief Nurse) at 18WS (07803068137) so that your details can be recorded.
Did you have any difficulty using the Covid test kit?
- Yes
- No
Please explain what the issue was?
Confirmation*
I confirm that I have carried out this test as per the guidelines outlined
- Please tick if you only have 5 test kits left and require more kits
Thank you.

18 Week Support