Please ensure you have read the previous page and fully understand the testing requirements for your individual situation. Village Health takes no responsibility for extra costs incurred as a result of incorrect information being supplied. Contact Us Name(Required) As written on your passportDate of birth(Required) Gender(Required) Email(Required) Phone(Required)Your best contact phone numberTravel detailsDate(Required) MM slash DD slash YYYY Date of departure from New ZealandTime(Required) Hours : Minutes AM PM Time of departing flightDestination(Required) Your final destinationAirline and flight number(Required) Please upload a copy of the identification page of your passport here(Required)Max. file size: 256 MB.Current COVID risk detailsHave you travelled outside of New Zealand, including Australia within the last 14 days?(Required) No Yes If Yes, please provide date and country travelled to Have you had close contact with any person within an MIQ (Managed Isolation Quarantine) or border control within the last 14 days?(Required) No Yes If Yes, please provide details of contact Have you had contact or been in a location with a confirmed or probable case of COVID within the last 14 days?(Required) No Yes If Yes, please provide details of contact Have you had any of the following symptoms within the last 14 days: fever (greater than 38 degrees celcius), runny nose, sore throat, loss of smell, cough?(Required) No Yes If Yes, please provide details of your symptoms DisclaimerConsent(Required) I have read and agree to the terms and conditions as outlined belowI understand that Village Health is not responsible for providing details of travel requirements for different destinations or airlines. I understand that if I do not get my result back in time to satisfy requirements stipulated by either NZ or destination/airline country, I am liable for any costs or losses incurred including but not limited to airfares, further testing costs, insurance etc. I confirm that the details provided are my own and are true and correct. I understand that all information provided to Village Health will be handled in accordance with the Privacy Act 1993.