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COVID-19 Self test Rapid Antigen
A copy of this form will also be sent to this email once submitted, sometimes this may appear in the junk/spam folder. If you have not received your confirmation AFTER submission, please contact us and we can provide a PDF of the form you have submitted.
The email will used to send the tracking information for delivery.
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Email
*
Your email
Please complete this form before you collect or have your kits delivered to you
IMPORTANT: Please ensure ALL details are correct
Disclaimer:
- Results may be negative, positive, or unclear.
- The test is non-refundable once kits are collected/delivered.
Please follow the Government guidelines
For the latest guidance visit:
https://www.gov.uk/coronavirus
Please read and tick each statement to indicate that you understand
*
I understand
This is a home test i.e. you have to do the test yourself as per the instructions
This CANNOT be used to obtain a Fit to fly for travellers leaving the UK
Certificates will be NOT issued
I understand
This is a home test i.e. you have to do the test yourself as per the instructions
This CANNOT be used to obtain a Fit to fly for travellers leaving the UK
Certificates will be NOT issued
Transaction ID from PayPal
*
Please enter your Transaction ID, which you should have received in an email from PayPal after making the payment. This is so we can link your booking with the payment. If you have not made the payment then please follow the instructions on our website:
https://www.yakubchemist.co.uk/community-retail-pharmacy/#covid19-testing-services
Your answer
How many kits have you purchased?
*
Your answer
How will you like to receive your tests?
*
Delivery has extra charge. Delivery will be to the address given above. Please note: Deliveries are Mon-Fri ONLY, excluding bank holidays
Delivery via courier: Mon - Fri only (excluding bank holidays)
Collection from Yakub Chemist: Mon to Sun during opening hours (including bank holidays)
Expected date of collection or delivery
*
Click the calendar icon to select date. Delivery ONLY MON-SAT. *OPENING HOURS: MON-FRI: 9AM-1PM, 2PM-7PM, SAT: 9AM-6PM, SUN:10AM-4PM. BANK HOLIDAYS: 10AM-4PM. NOTE: LAST APPOINTMENT 30MINUTES BEFORE CLOSING
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/
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First name
*
If you have purchased kits for more than one person, please put only one person's name
Your answer
Surname
*
If you have purchased kits for more than one person, please put only one person's name
Your answer
Delivery address/collection confirmation address:
*
Please include first line of address, city, and postcode in the UK where you would like your kits to be delivered to. If you are collecting then we will ask you to confirm this address upon collection
Your answer
UK Mobile number
*
This will be used to send the tracking information
Your answer
Please read the following statements and tick if you understand:
*
*OPENING HOURS: MON-FRI: 9AM-1PM, 2PM-7PM, SAT: 9AM-6PM, SUN:10AM-4PM. BANK HOLIDAYS: 10AM-4PM.
I agree and understand
Results may be negative, positive, or unclear. The test is non-refundable once sample is taken, irrespective of the results or circumstances.
I have completed the form for the correct type of test I require
This test CANNOT be used to obtain a fit to fly certificate
I agree and understand
Results may be negative, positive, or unclear. The test is non-refundable once sample is taken, irrespective of the results or circumstances.
I have completed the form for the correct type of test I require
This test CANNOT be used to obtain a fit to fly certificate
Where did you hear about us?
*
Google (search engine)
Social media (Instagram, Facebook, Twitter)
Through family/friends
Repeat customer (Used PCR Testing service at Yakub Chemist previously)
Government list of private test providers
Pharmacy staff
Leaflet/poster in the pharmacy
A copy of your responses will be emailed to the address you provided.
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