covidtestformnorthshore

Are you in a car or on foot?

Name *

First

Middle

Last

Gender *

Date of birth

Date/Month/Year

Is this your first Covid test?

Phone *

Are you a New Zealand citizen or permanent resident?

Address

Address line 1

Address line 2

City

NHI number (if known)

Email

How 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?)

Have you had contact with a confirmed or probable COVID case in the last 14 days?)

Do you work as a healthcare worker or do you work in a healthcare facility including aged residential care

Are you currently working as one of the essential services, eg supermarket, prisons, fire, rescue services?)

Do you reside in a communal environment eg aged residential care, prisons, large extended family, university hall of residence, hostel or shelter?)

Surveillance code

If you have a voucher or surveillance code please enter the code here

For covid testing please complete this form for a faster service