COVID Recovery Form Questionnaire

Full Name*

First Last

Date of Birth*

Phone*

Email*

Address*

Street Address City County Post Code Country

Passport Number*

Can you confirm the date of your positive PCR or lateral flow?*

Since then have you had a negative lateral flow?*

What date was your negative lateral flow?*

Do you have any current symptoms?*

What is your vaccination status? *

What was the date of your booster vaccination?*

Are you fully recovered and have no Covid-19 symptoms?

Upload an evidence of Covid-19 positive result within 180 days*

These documents can include Positive PCR Text Notification, Positive PCR Email Notification, NHS Validated Positive Lateral Flow Test or a Positive Test Certificate.

Accepted file types: jpg, jpeg, png, pdf, doc, docx, Max. file size: 2 MB.

COVID Recovery Form Questionnaire

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