Community Pharmacy Antibody Test Form AttendedYesNoResult ReceivedYesNoDemographics ConfirmedYesNoUser Unique IDReason For TestingPrimary CareSecondary CareCommunity CareSocial CarePersonal DetailsName*Please ensure you use your legal name (as found on your passport for example) First Last Email Address* Enter Email Confirm Email Create Password* Enter Password Confirm Password Strength indicator Mobile Phone Number*NHS NumberHow I can find my NHS NumberNHS Number*How I can find my NHS Number Staff NumberDate of Birth* DD MM YYYY Address* Street Address Address Line 2 Town County Post Code Sex*MaleFemaleEthnicity*White BritishWhite IrishWhite Any other White backgroundMixed White and Black CaribbeanMixed White and Black AfricanMixed White and AsianMixed Any other mixed backgroundAsian or Asian British IndianAsian or Asian British PakistaniAsian or Asian British BangladeshiAsian or Asian British Any other Asian backgroundBlack or Black British CaribbeanBlack or Black British AfricanBlack or Black British Any other Black backgroundOther Ethnic Groups ChineseOther Ethnic Groups Any other ethnic groupNot StatedOrganisationGP-Other101 OXFORD ROAD240 WEXHAM ROADABBEY MEDICAL CENTREALBANY PRACTICEALDERSHOT MEDICAL CENTREALEXANDER HOUSE SURGERYAMERSHAM HEALTH CENTREARBORFIELD MEDICAL CENTREARGYLE HEALTH-ISLEWORTH PRACTICEASCOT MEDICAL CENTREASHFORD HEALTH CENTREASHLEY MEDICAL PRACTICEASSURA NORTH SURREYAUSTEN ROAD SURGERYB & A CCG EXTENDED HOURS SERVICEBADGERSWOOD SURGERYBAKER STREET CLINICBALFRON PRACTICEBALMORE PARK SURGERYBARTLETT GROUP PRACTICEBATH ROAD SURGERYBHARANI MEDICAL CENTREBINFIELD SURGERYBINSCOMBE MEDICAL CENTREBLUE WING FAMILY DOCTOR UNITBOUNDARY HOUSE SURGERYBOURNE END & WOOBURN GREEN MEDICAL CTRBRANKSOMEWOOD H/CARE CTRBRENTFORD FAMILY PRACTICEBRENTFORD GROUP PRACTICEBRIDGE PRACTICEBROOKSIDE PRACTICEBURDWOOD SURGERYBURMA HILL PRACTICEBURNHAM HEALTH CENTRECAMBERLEY HEALTH CENTRECARLTON SURGERYCARRINGTON HOUSE SURGERYCAVALRY MEDICAL CENTRECEDAR HOUSE PRACTICECHAPEL MEDICAL CENTRECHAPEL ROW SURGERYCHATHAM STREET SURGERYCHERRYMEAD SURGERYCHERTSEY HEALTH CENTRECHESTNUT PRACTICECHIDDINGFOLD SURGERYCHILTERN HOUSE MED CENTRECHISWICK FAMILY DRS PRACTICECHISWICK HEALTH PRACTICECHOBHAM & WEST END MEDICAL PRACTICECHURCH STREET PRACTICECIRCUIT LANE SURGERYCLAREMONT HOLYPORT SURGERYCLARENCE MEDICAL CENTRECLEVES SURGERYCLIFFORD HOUSE MEDICAL CENTRECLIFFORD ROAD SURGERYCOBHAM HEALTH CENTRECOMBERMERE MEDICAL CENTRECONCORDIA HEALTH GROUP (LEATHERMARKET)COOKHAM MEDICAL CENTRECORDWALLIS ROAD SURGERYCRANE PARK SURGERYCRANFORD MEDICAL CENTRECRANLEIGH MEDICAL PRACTICECRONDALL NEW SURGERYCROSBY HOUSE SURGERYCROSSLANDS SURGERYCROUCH OAK FAMILY PRACTICECROWN WOOD MEDICAL CENTREDAPDUNE HOUSE SURGERYDATCHET HEALTH CENTREDEEPCUT MEDICAL CENTREDENHAM MEDICAL CENTREDESBOROUGH SURGERYDOWNING STREET GROUP PRACTICEDR AH SHAH'S PRACTICEDR FIRTH AND PARTNERSDR NABIDR R J POOLDR S MORCOSDR SOOD'S PRACTICEEARLSWOOD MED PRACTEASTFIELD HOUSE SURGERYEASTHAMPSTEAD SURGERYELDON ROAD SURGERYELIZABETH HOUSE MEDICAL PRACTICEELM ROAD PRACTICEEMMER GREEN SURGERYESHER GREEN SURGERYEVERGREEN PRACTICEFAIRLANDS MEDICAL PRACTICEFALKLAND SURGERYFARNHAM DENE MEDICAL PRACTICEFARNHAM ROAD PRACTICEFINCHAMPSTEAD PRACTICEFIRSTCARE PRACTICEFLEET MEDICAL CENTREFORDBRIDGE MEDICAL CENTREFOREST HEALTH GROUPFORT HOUSE SURGERYGIBRALTAR MEDICAL CENTREGIBSONGIFFARD DRIVE SURGERYGILL MEDICAL PRACTICEGLEBE STREET SURGERYGOLDSWORTH PARK HEALTH CENTREGORING & WOODCOTE MEDICAL PRACTICEGRAYSHOTT SURGERYGREAT HOLLANDS PRACTICEGREEN MEADOWS SURGERYGREEN PRACTICEGREENBROOK BEDFONTGREENBROOK BROADWALKGREENBROOK CHINCHILLAGROVE MEDICAL CENTREGROVE PARK SURGERYGROVE PARK TERRACE SURGERYGROVE VILLAGE MEDICAL CENTREGROVELANDS MEDICAL CENTREGUILDFORD RIVERS PRACTICEGUILDOWNS GROUP PRACTICEHAMPTON HILL MEDICAL CENTREHASLEMERE HEALTH CENTREHATTON MEDICAL PRACTICEHAWTHORNS SURGERYHEADLEY MEDICAL CENTREHEATH HILL SURGERYHEATHCOT MEDICAL PRACTICEHEATHERSIDE SURGERYHERMITAGE MEDICAL CENTREHERSCHEL MEDICAL CENTREHERSHAM SURGERYHIBERNIA HOUSE SURGERYHIGHFIELD SURGERYHILLVIEW MEDICAL CENTREHMC HEALTH HESTON GREAT WESTHOLLY ROAD MEDICAL CENTREHOLLY TREE SURGERYHOLYPORT SURGERYHOMEWATERSHOUNSLOW FAMILY PRACTICEHOUNSLOW MEDICAL CENTREHUGHENDEN VALLEY SURGERYHUNGERFORD SURGERYHYTHE MEDICAL CENTRE SURGERYIBRAHIM & PARTNERSIVER MEDICAL CENTREJADALIZADEHJENNER HOUSE SURGERYJERSEY PRACTICEJOHAL (TWICKENHAM PARK)KENNET SURGERYKEOGH MEDICAL CENTREKINGFISHER PRACTICEKINGS CORNER SURGERYKINGSWOOD SURGERYKINTBURY & WOOLTON HILL SURGERYKNOWLE GREEN MEDICALKUMAR MEDICAL CENTRELAMBOURN SURGERYLANE END SURGERYLANGLEY HEALTH CENTRELEE HOUSE SURGERYLIGHTWATER SURGERYLINDEN MEDICAL CENTRELIPHOOK AND LISS SURGERYLIPHOOK VILLAGE SURGERYLITTLE CHALFONT SURGERYLITTLE PARK SURGERYLODDON VALE PRACTICELONDON ROAD SURGERYLONDON STREET SURGERYLONG BARN LANE SURGERYLOXWOOD SURGERYMADEIRA MEDICALMAGNOLIA HOUSE SURGERYMANOR HOUSE PRACTICEMANOR PARK MEDICAL CENTREMAYBURY SURGERYMAYFIELD MEDICAL CENTREMEADOWCROFT SURGERYMEDICAL CENTREMELROSE SURGERYMELROSE SURGERY DR FAB WILLIAMSMERROW PARK SURGERYMILL STREAM SURGERYMILLBARN MEDICAL CENTREMILLSIDE SURGERYMILMAN ROAD SURGERYMOAT HOUSE SURGERYMONTEAGLE SURGERYMORTIMER SURGERYMOUNT MEDICAL CENTRENETTLEBED SURGERYNEW INN SURGERYNEW OTTERSHAW SURGERYNEW WOKINGHAM ROAD SURGERYNORTH CAMP SURGERYNORTHCROFT SURGERYNWS INTEGRATED CARE SERVICES (NICS)O'DONNELL (CROSS DEEP)ODIHAM MEDICAL CENTREOLD DEAN SURGERYPARISHES BRIDGE MED.PRACTPARK HOUSE SURGERYPARK ROAD GROUP PRACTICEPARKFIELD PRACTICEPARKLANDS SURGERYPARKSIDE PRACTICEPEASLAKE SURGERY & DISP.PEMBROKE SURGERYPENTELOW PRACTICEPEPPARD ROAD SURGERYPINEHILL SURGERYPIRBRIGHT MEDICAL CENTREPIRBRIGHT SURGERYPOND TAIL SURGERYPRINCES GARDENS SURGERYPRIORY AVENUE SURGERYPRIORY SURGERYPROCARE HEALTH SERVICESQUEENS PARK MEDICAL PRACTICERAGSTONE ROAD SURGERYREADING WALK-IN HEALTH CENTRERECTORY MEADOW SURGERYREDWOOD HOUSE SURGERYREDWOOD PRACTICERICHMOND SURGERYRINGMEAD MEDICAL PRACTICERIVER WEY MEDICAL PRACTICERIVERSIDE SURGERYROCHESTER PRACTICEROSEMEAD SURGERYROSS ROAD MEDICAL CENTREROWAN TREE PRACTICERUDGWICK MEDICAL CENTRERUNNYMEDE MEDICAL PRACTICERUSSELL STREET SURGERYSANDHURST MEDICAL CENTRESARAJLIC (STAINES ROAD)SHEERWATER HEALTH CENTRESHEET STREET SURGERYSHEPPERTON MEDICAL PRACTICESHERE SURGERY/DISPENSARYSHINFIELD MEDICAL PRACTICESHREEJI MEDICAL CENTRESKYWAYS MEDICAL CENTRESLOUGH EXTENDED HOURS SERVICESLOUGH TREATMENT, ADVICE & RECOVERY TEAMSMALLFIELD SURGERYSONNING COMMON HEALTH CTRSOOD (THE GREEN & FIR ROAD)SOUTH MEADOW SURGERYSOUTH READING & SHINFIELD GROUP MED PRACSOUTHMEAD SURGERYSOUTHVIEW MEDICAL PRACTICESOUTHWOOD PRACTICESPRING GROVE MEDICAL PRACTICESPRINGFIELD SURGERYST DAVID'S FAMILY PRACTICEST DAVIDS PRACTICEST JOHN'S FAMILY PRACTICEST. LUKE'S SURGERYST. MARGARETS PRACTICEST. NICOLAS SURGERYSTAINES HEALTH GROUPSTAINES THAMESIDE MEDICALSTANWELL ROAD SURGERYSTATION ROAD SURGERYSTRAWBERRY HILL MEDICAL CENTRESTUDHOLME MEDICAL CENTRESUNBURY GROUP PRACTICESUNNY MEED SURGERYSUSSEX COMMUNITY DERMATOLOGY SERVICE (HOVE)SWALLOWFIELD MEDICAL PRACTICESWAN MEDICAL GROUPTAPLOW HEALTH CENTRETHATCHAM HEALTH CENTRETHE 303 BATH ROAD SURGERYTHE ALLAN PRACTICETHE AVENUE MEDICAL CENTRETHE BELL SURGERYTHE BOAT HOUSE SURGERYTHE BORDER PRACTICETHE CAMBRIDGE PRACTICETHE CEDARS SURGERYTHE DOCTORS HOUSE, MARLOW MEDICAL GROUPTHE DOWNLAND PRACTICETHE FERNS MEDICAL PRACTICETHE GAINSBOROUGH PRACTICETHE HALL PRACTICETHE HART SURGERYTHE HORSLEY MEDICAL PRACTICETHE JOHN HAMPDEN SURGERYTHE MANDEVILLE PRACTICETHE MILL MEDICAL PRACTICETHE MISBOURNE SURGERYTHE OAKLANDS PRACTICETHE OAKLEY HEALTH GROUPTHE OASIS MEDICAL CENTRETHE ORCHARD SURGERYTHE PRACTICE COLLEGE ROADTHE PRACTICE FELTHAMTHE PRACTICE HEART OF HOUNSLOWTHE RED PRACTICE WALTONTHE SANDHURST GROUP PRACTICETHE SIMPSON CENTRETHE SYMONS MEDICAL CENTRETHE VILLAGE MEDICAL CENTRETHE WALL HOUSE SURGERYTHE WATERFIELD PRACTICETHE WELLINGTON PRACTICETHE YELLOW PRACTICETHEALE MEDICAL CENTRETHORNBURY ROAD CENTRE FOR HEALTHTHREEWAYS SURGERYTILEHURST SURGERY PARTNERSHIPTILEHURST VILLAGE SURGERYTOWER HOUSE SURGERYTOWNHILL MEDICAL PRACTICETWICKENHAM PARK MEDICAL CENTRETWYFORD SURGERYUNIVERSITY MEDICAL GROUPUPPER GORDON ROAD SURGERYUPPER HALLIFORD MEDICAL CENTREVICTORIA MEDICAL CENTREVICTORIA PRACTICEVILLAGES MEDICAL CTRVIRGINIA WATER MEDICAL PRACTICEVOYAGER FAMILY HEALTHWALLINGFORD MEDICAL PRACTICEWAM CCG PMCF (7 DAY WORKING WINDSOR)WARGRAVE PRACTICEWARLINGHAM GREEN MED PRACWATER MEADOW SURGERYWELLESLEY ROAD PRACTICEWEST4 GPSWESTERN ELMS & CIRCUIT LANE SURGERIESWESTONGROVE PARTNERSHIPWESTWOOD ROAD SURGERYWEXHAM ROAD SURGERYWEY FAMILY PRACTICEWHITEWATER HEALTHWHITLEY VILLA SURGERYWHYTELEAFE SURGERYWILDERNESS PRACTICEWILLOW PRACTICEWITLEY SURGERYWOKING LOCALITY HUBWOKINGHAM MEDICAL CENTREWONERSH SURGERYWOODBRIDGE HILL SURGERYWOODLANDS PARK SURGERYWOODLEY PRACTICEWOOSEHILL PRACTICEWRAYSBURY MEDICAL CENTREWYE VALLEY SURGERYOccupation SelectManagers / Directors and Senior Officials (any sector)Professional OccupationsAssociate professional occupations (Includes technicians)Administrative Occupations (Includes Secretaries & Assistants)Skilled Trade Occupations (Includes Chefs)Caring / Leisure and Civil EnforcementSale & Customer service Occupations (Includes Pharmacy Dispensing Assistants and Call Centre staff)Process / Plant and Machine Operative (Includes food processing and road construction)Transport and Mobile Machine Drivers and OperativesManual and Routine OccupationsRetiredStudent - higher educationSchool-aged studentsNot currently working Select Select 'Other' GP DetailsGP OrganisationSouth 5 COVID portalGP Code92ASymptom Check*Have you had a high temperature, a continuous cough, or a loss or change to your sense of smell or taste since 01 January 2020?YesNo21 Day Check*Have you had these symptoms in the last 21 days?YesNoTo ensure the optimal success of detecting exposure to SARS-CoV-2, national guidance states that NHS staff should only be tested once they have been free of symptoms for 21 days. Since you have selected yes, the antibody test will not be affective and you should re-register after being symptom free for 21 days.LocationSelect from available test locationsSelect test location SH - CPH - MTC - Spectrum Car Park, Parkway, Guildford GU1 1UP SH - CPH - Surrey Heartlands CCG - Weybridge - KT13 8DP SH - CPH - MTC - Leatherhead - Leisure Centre car park KT22 9AS SH - CPH - MTC - Reigate - Woodhatch car park - RH2 8BF SH - CPH Vitaltone Pharmacy, Caterham - CR3 6QA Appointment*If you are unable to select a clinic date, this is because all available slots have been filled. Your employer will update you when new clinics have been opened. January 2022 Sun Mon Tue Wed Thu Fri Sat 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 What is an antibody test? An antibody test can tell someone whether they have had the virus that causes Covid-19 in the past, by analysing a blood sample. What do antibody test results mean? A positive antibody test demonstrates that someone has developed antibodies to the virus. The presence of antibodies signals that the body has staged an immune response to the virus. Covid-19 is a new disease, and our understanding of the body’s immune response to it is limited. We do not know, for example, how long an antibody response lasts, nor whether having antibodies means you can’t transmit the virus to others. Our understanding of the virus will grow as new scientific evidence and studies emerge. An antibody test result can only tell an individual whether or not they have had the virus in the past. Antibody tests are also being used currently in surveillance studies, to understand what proportion of the population have already had the virus. If you test positive for antibodies, can you ignore lockdown restrictions? No. There is no evidence yet to suggest that those who have been proven to have had the virus are immune. This is the position of the World Health Organisation. You should continue to comply with social distancing measures and government guidelines. All infection prevention and control measures must continue to be in place irrespective of the presence of antibodies. How will I be informed of the result? Communication of the result is the responsibility of your employing organisation. The results will not go on the employment record and your GP should be able to access the result if required and according to local information sharing protocols. How will my information be used? The anonymised results across the testing programme will provide information on the prevalence of COVID-19 in different regions of the country and help better understand how the disease spreads. Are there any risks to having the test? There are some risks related to having a blood test, such as feeling dizzy and faint during and after the test but nothing specific to this antibody test. Risks can also include bruising at the venepuncture site. Serious complications such as an infection at the site where blood was taken and phlebitis (swelling of the vein) are possible but generally extremely unlikely.ConsentI have had the opportunity to consider the information and can confirm that I understand the nature and purpose of this procedure, together with the benefits and risks.*YesI have confirmed a positive test will not mean at this point that I am immune and therefore I will continue to behave as if I might get or pass on the infection*YesI confirm that I have read the above information; I understand that my participation is voluntary and I consent for this procedure*YesI declare that the information I have given on this form is correct and complete.*YesDo you give permission to be contacted in the future if needed for research purposes?*YesNoRight now antibody testing is supporting the on-going scientific research being undertaken nationally and there is no strong evidence yet to suggest that those who have been proven to have had the virus are immune. The value of antibody tests therefore is currently limited to answering the question of whether someone has had the virus or not. If you receive a positive antibody result it does not mean that you are immune, or that you cannot pass on the virus to others. In order to support the research being undertaken and ultimately the evidence around immunity, there is a requirement for personal data to be shared between organisations. This is a priority nationally and will aid the wider response to Covid-19. It is on this basis that Surrey Heartlands must prioritise those NHS staff willing to take part in the research. Those who would prefer not to share their data will still be offered an antibody test, however they will be placed on a waiting list and contacted once the initial stage of antibody testing has commenced.Consent Date Date Format: DD slash MM slash YYYY Signature*PhoneThis field is for validation purposes and should be left unchanged.