Serology Pop Up Clinic Registration Form Please do not use this form unless you are attending a serology pop-up clinic. Download Serology Testing FAQs. Step 1 of 2 50% ConsentI confirm that I have read the above information; I understand that my participation is voluntary and I consent for this procedure. I have had the opportunity to consider the information and can confirm that I understand the nature and purpose of this procedure, together with the benefits and risks. I have confirmed a positive test will not mean at this point that I am immune and therefore I will continue to behave as if I might get or pass on the infection I declare that the information I have given on this form is correct and complete. I consent to my blood sample being held for up to a year. Your consent*I agreeI disagreeUnfortunately we are unable to offer an antibody test without your agreement to the consent criteria. Your detailsName* Mr.Mrs.MissMs.Dr.Prof.Rev. Prefix First Last Date of birth* Home address* Street Address Address Line 2 City Post code Your personal mobile phone number*This may be the number we use to share results with you.Personal email address* We will use this to confirm your appointment details with you.Job role*Location*Have you had a previous Covid swab with a positive result?*YesNoDate of swab*EthnicityEthnic origin*Asian or British AsianBlack or Black BritishMixedWhiteOther ethnic groupPrefer not to sayAsian or British Asian*BangladeshiIndianPakistaniWhite*BritishIrishBlack or Black British*AfricanCaribbeanMixed*White & AsianWhite & Black AfricanWhite & Black CaribbeanOther*ChineseCurrent Health StatusHave you had a new onset of any of the following symptoms in the past 5 days?* Cough Temperature Loss of or change in normal sense of taste or smell None of the above Please be advised self-isolation is required for a new onset of temperature and/or cough and/or loss of taste/smell. Please access Covid-19 swab testing via the links below. Serology testing can be accessed following isolation period (duration result dependent). GHC testing service at Brockworth National Testing Service Have you had a new onset of any other minor illness in the last 5 days?* Headache Sore throat Wheezing Itchy/red eyes Nasal discharge or congestion Shortness of breath No other minor symptoms If you have any of these symptoms, a swab may be required during the Serology testing appointment.About your appointmentIt is important that we take steps to help prevent the spread of infection while clinics are running: Colleagues taking blood samples will be wearing PPE If you are having blood taken, you will be required to wear a face covering, such as a scarf or fabric mask. Do not use Trust stocks of PPE Attend your appointment punctually and wait outside the building until your allotted time. Appointment length is approximately 10 minutes. If you are late for your appointment you may need to rebook. You will be unable to use facilities, such as toilets and rest areas so please bear that in mind before setting off for your appointmentPhoneThis field is for validation purposes and should be left unchanged.