For covid testing please complete this form for a faster service Please enable JavaScript in your browser to complete this form.123Are you in a car or on foot?CarFootHow many people in your car need testing?Please complete this form for evey person who needs a test. E.g. if there are 3 people who need a test, each one will need to complete this form. Enter your licence code (see text message)Name *FirstMiddleLastGender *MaleFemaleDate of birthDate/Month/YearIs this your first Covid test?YesNoPhone *Ethnic Group: Tick as many boxes as you need to show which ethnic groups you belong to:NZ EuropeanMaoriTonganChineseCook Island MaoriSamoanNiueanIndianOther (Eg Dutch, Japanese, Tokelauan)Please state:Are you a New Zealand citizen or permanent resident?YesNoWhich visa do you hold?Visitor Work StudentNextAddressAddress line 1Address line 2CityNHI number (if known)EmailNextDo you have any of the following symptoms?AllCoughSore throatRunny noseShortness of breathLoss of sense of smellFever/ChillsOtherNoneDo you have any of these symptoms?AllDiarrhoeaHeadahceMuscle achesNausea/VomitingConfusion/IrritabilityNoneHow unwell do you feel on a scale of 0 to 10 with 0 having no symptoms and 10 needing hospitalisation?Have you travelled overseas or had contact with a person who has travelled overseas past 14 days?)YesNoUnknownDate returned to NZ?Have you had contact with a confirmed or probable COVID case in the last 14 days?)YesNoUnknownName of person who you have had contact with (this helps ARPHS link the case) Contact of > 15 minutes and < 2m distance YesNoDo you work as a healthcare worker or do you work in a healthcare facility including aged residential careYesNoUnknownRole performedPlace of workDHB employeeAged residential carePrimary careCBAC/testing centreOtherWhich DHB?NDHBADHBWDHBCMDHBName and address of aged residential care facilityPrimary care detailsCBAC/testing centre detailsOther place of workAre you currently working as one of the essential services, eg supermarket, prisons, fire, rescue services?)YesNoRole detailsDo you reside in a communal environment eg aged residential care, prisons, large extended family, university hall of residence, hostel or shelter?)YesNoUnknownPlace of residenceAged residential careHostel/ShelterUniversity residenceOtherName and address of aged residential facilityHostel/shelter detailsUnversity residence detailsOther place of residenceSurveillance codeIf you have a voucher or surveillance code please enter the code hereSubmit