Pre-operative Covid-19 Screening Referral form for pre-operative Covid-19 testing via Gloucestershire Health and Care NHS Foundation TrustStep 1 of 250%Does the patient know they are required to attend the drive through testing service at Brockworth to have their swab? * REQUIREDYesNoDoes the patient have access to private transport?YesNoPlease contact usAll patient's will need to visit our drive through testing pod in Brockworth, Gloucester. They will need access to private transport to do this. If they are unable to do this, please contact us to discuss alternative options - 0300 421 8243Referrer informationThe referrer is the person completing this formReferrer's Name * REQUIRED First Last Name of person completing this formReferrer's telephone number * REQUIREDWe may need to contact you about the referral.Referrer's email * REQUIRED Type of referral * REQUIREDPre-procedurePre-placementVulnerable patient, not suitable for Pillar 2 testingOtherThis is a drop down boxDate of procedure or placement (TCI) - must be dd/mm/yyyy format * REQUIRED The test will take place 72 hours before this dateLocation of this procedure or placement * REQUIREDAny additional information regarding swab date, location etcWho's activity? * REQUIREDGloucestershire Health and Care NHS FTGloucestershire Hospitals NHS FTGP careIn healthOtherThis is a drop down menu. Which organisation is providing care for this patient? This may be different to the location of the procedure or placement.Patient's informationPatient's Name * REQUIRED Mr.Mrs.MissMs.Dr.Prof.Rev. Prefix First Last Date of birth * REQUIRED DD MM YYYYAddress * REQUIRED Street Address Address Line 2 City Post Code Patient's NHS number * REQUIREDPatient's contact number * REQUIREDThis is the number we will use to arrange the testDoes the patient have any Covid symptoms? * REQUIREDYesNoI don't knowHas the patient or anyone they have had contact with travelled outside the UK in the last 10 days? * REQUIREDYesNoI don't knowPlease give details: * REQUIREDDo you have any additional information that would help with this referral?Has the patient consented to this Covid test? * REQUIREDYesNoI don't know