Patient COVID-19 Test Request Form

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Personal Information

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COVID-19 Information
Symptoms. Please tick as many as apply to you
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In order to provide your care we need to collect sensible personal and medical information. We recognise the importance of protecting data personal medical records in all that we do, and take care to meet our legal and other duties, including compliance with relevant law, Medical Council regulations and guidance. Under the General Data Protection Regulation (GDPR) Central Park Medical is obliged to ensure patient data, supplied as part of the patient process.

I agree that my personal details could be and will be used for medical purposes. I confirm that all the information I provided is correct.

Thanks for submitting!