Laboratory form | Allergy testing

Remote UKallergy: ALEX³ Test Order Form, Symptom Questionnaire and Card Payment

Please complete this questionnaire based on your own personal experience and current symptoms. To help our consultants interpret your results accurately, we ask that you describe your own experience rather than referring to previous test results or diagnoses. (If you are completing this form on behalf of a child or a relative, please provide their details and experiences in the sections below.) When you receive your results, you can book an appointment with an allergy consultant through our electronic health record system. Please click HERE to register for an account at ukallergy.carebit.co (opens in a new tab). This will allow you to access your results and book a consultation to discuss them if required. If you need any help please contact our custormer support by email.

Step 1 of 11

First Name*
Last Name*
Gender*
- Male
- Female
Date of Birth*
DD slash MM slash YYYY
Email*
Enter Email Confirm Email
Phone*
Address*
Address City Post code Country

Section 3 - Pets
Do you have any pets at home?
- Yes
- No
If yes, please give details (E.g. long haired dog)
How long have you had the pet(s)?
Does the pet have full run of the house?
- Yes
- No
Does the animal sleep on your bed?
- Yes
- No
Does exposure make the symptoms worse?
- Yes
- No

Section 5 - Food Allergies
Do you have any food allergies?
- Yes
- No
Please give details of any food allergies/sensitivity and briefly describe the reaction. Please state if the reaction is immediate or delayed:
If any, please give details of foods you avoid and why:

Other details
If you have any further information to add on any aspect of your condition, please do so below.

I give permission for a blood sample to be collected from a finger-prick or a vein, for the purpose of a specific IgE test. This is a required field.*
- Agreed
I give permission for a copy of the results to be sent to my GP. This is a required field.
- Agreed
- Disagree
GP's Address if selecting Agreed from above
Street Address Address Line 2 City Country Post Code Country
I give consent for the use of anonymised information from this questionnaire and test results for teaching, audit and research purposes. This is a required field.*
- Agreed
Payment and sample collection*
- Agree to have allergy test done
Once you have paid the fee via our secure Worldpay system, your testing kit will be sent out to your home address. You will get an e-mail with a link to full video instructions on how to collect the sample from a finger prick. (if you are not comfortable with collecting your own sample please do not make a payment and contact our office on info@ukallergy.com instead we will discuss alternative arrangements with you). For children the sample needs to be collected by a healthcare professional. You confirm that you agree with the refund policy and communication policy.
ISAC Test Payment*
Price:

Remote UKallergy: ALEX³ Test Order Form, Symptom Questionnaire and Card Payment

Step 1 of 11

Section 1 - About You

Section 2 - Your Environment

Bedroom Details

Section 3 - Pets

Section 4 - Your allergies and symptoms

Seasonal Incidence of your Allergy

Section 5 - Food Allergies

Section 6 - Hay fever/Pollen allergy

Section 7 - Insect Allergy

Section 8 - Asthma

Other details