Pre-operative and other 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
The referrer is the person completing this form
Referrer's Name * REQUIRED
First Last
Name of person completing this form
Referrer's telephone number * REQUIRED
We may need to contact you about the referral.
Referrer's email * REQUIRED
Type of referral * REQUIRED
This is a drop down box
Date of procedure or placement (TCI) - must be dd/mm/yyyy format * REQUIRED

The test will take place 72 hours before this date
Location of this procedure or placement * REQUIRED
Any additional information regarding swab date, location etc
Who's activity? * REQUIRED
This 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 information
Patient's Name * REQUIRED
Prefix First Last
Date of birth * REQUIRED
DD
MM
YYYY
Address * REQUIRED
Street Address Address Line 2 City Post Code
Patient's NHS number * REQUIRED
Patient's contact number * REQUIRED
This is the number we will use to arrange the test
Does the patient have any Covid symptoms? * REQUIRED
- Yes
- No
- I don't know
Has the patient or anyone they have had contact with travelled outside the UK in the last 10 days? * REQUIRED
- Yes
- No
Please give details: * REQUIRED
Do you have any additional information that would help with this referral?
Has the patient consented to this Covid test? * REQUIRED
- Yes
- No
- I don't know

Pre-operative Covid-19 Screening