Pre-operative Covid-19 Screening > Gloucestershire Health and Care NHS Foundation Trust

Does the patient know they are required to attend the drive through testing service at Brockworth to have their swab? * REQUIRED
- Yes
- No
Does the patient have access to private transport?
- Yes
- No
Please contact us
All 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 8243

Referrer information
Referrer's Name * REQUIRED
First Last
Referrer's telephone number * REQUIRED
We may need to contact you about the referral.
Referrer''s email * REQUIRED
Type of referral * REQUIRED
Date of procedure or placement for the following patients - must be dd/mm/yyyy format * REQUIRED
Patient 1
1. Patient's Name * REQUIRED
Prefix First Last
1. Date of birth * REQUIRED
DD
MM
YYYY
1. Address * REQUIRED
Street Address Address Line 2 City Post Code
1. Patient's NHS number * REQUIRED
1. Patient's mobile number * REQUIRED
This may be the number we use to share results.
1. Additional information
1. Location of procedure or placement * REQUIRED
1. Who's activity? * REQUIRED
1. Has the patient consented to this test? * REQUIRED
- Yes
- No
1. Please tick if you would like to add another patient
- Yes

Patient 2
2. Patient's Name * REQUIRED
Prefix First Last
2. Date of birth * REQUIRED
DD
MM
YYYY
2. Address * REQUIRED
Street Address Address Line 2 City Post code
2. Patient's NHS number * REQUIRED
2. Patient's mobile number * REQUIRED
This may be the number we use to share results.
2. Additional information
2. Location of procedure or placement * REQUIRED
2. Who's activity? * REQUIRED
2. Has the patient consented to this test? * REQUIRED
- Yes
- No
2. Please tick if you'd like to add another patient
- Yes

Patient 3
3. Patient's Name * REQUIRED
Prefix First Last
3. Date of birth * REQUIRED
DD
MM
YYYY
3. Address * REQUIRED
Street Address Address Line 2 City Post Code
3. Patient's NHS number * REQUIRED
3. Patient's mobile number * REQUIRED
This may be the number we use to share results.
3. Additional information
3. Location of procedure or placement * REQUIRED
3. Who's activity? * REQUIRED
3. Has the patient consented to this test? * REQUIRED
- Yes
- No
3. Please tick if you'd like to add another patient
- Yes

Patient 4
4. Patient's Name * REQUIRED
Prefix First Last
4. Date of birth * REQUIRED
DD
MM
YYYY
4. Address * REQUIRED
Street Address Address Line 2 City Post Code
4. Patient's NHS number * REQUIRED
4. Patient's mobile number * REQUIRED
This may be the number we use to share results.
4. Additional information
4. Location of procedure or placement * REQUIRED
4. Who's activity? * REQUIRED
4. Has the patient consented to this test? * REQUIRED
- Yes
- No
4. Please tick if you'd like to add another patient
- Yes

Patient 5
5. Patient's Name * REQUIRED
Prefix First Last
5. Date of birth * REQUIRED
DD
MM
YYYY
5. Address * REQUIRED
Street Address Address Line 2 City Post Code
5. Patient's NHS number * REQUIRED
5. Patient's mobile number * REQUIRED
This may be the number we use to share results.
5. Additional information
5. Who's activity? * REQUIRED
5. Location of procedure or placement * REQUIRED
5. Has the patient consented to this test? * REQUIRED
- Yes
- No

Pre-operative Covid-19 Screening