Family Name/Surname *

First Name *

Middle Name

Sex *

Female Male

Date of Birth *

Nationality *

Phone *

Email *

Contact Name

Contact Phone

Contact Residential Address

Country you are departing from *

State/City/Province of Departure

Do you hold a diplomatic passport *

No Yes

Passport Number *

Departure Terminal/Airport

Airline *

Flight Number

Seat Number

Arrival Location *

Date of Arrival *

Country of First Departure

Country of Transit

Country of Residence *

Residential Address

Countries Visited in the Last 21 days (departure country included)

State(s) you will be visiting while in Nigeria

In the last 21 days, have you had contact with anyone who was not feeling well?

No Yes

Have you undergone your pre-boarding COVID test ?

No Yes

COVID Test Result

Negative Positive

COVID Test Result Date

COVID Test Lab Name

Lab Phone

Lab Email

Lab Address

COVID Test Country

Attach COVID Test Result
Clients should be informed that their covid negative results must be valid for 72 hours before travel .

COVID-19 RT-PCR Test Client Information Form

Personal Information

Emergency or Next of Kin Contact in Nigeria

Travel Information

Additional Travel Information

Post Arrival COVID Test Questionnaire

Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Congo, the Democratic Republic of the
Cook Islands
Costa Rica
Cote D'Ivoire
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands (Malvinas)
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and Mcdonald Islands
Holy See (Vatican City State)
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran, Islamic Republic of
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libyan Arab Jamahiriya
Liechtenstein
Lithuania
Luxembourg
Macao
Macedonia, the Former Yugoslav Republic of
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia, Federated States of
Moldova, Republic of
Monaco
Mongolia
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestinian Territory, Occupied
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Reunion
Romania
Russian Federation
Rwanda
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia and Montenegro
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Swaziland
Sweden
Switzerland
Syrian Arab Republic
Taiwan, Province of China
Tajikistan
Tanzania, United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
United States Minor Outlying Islands
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.s.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe

Abia State
Adamawa State
Akwa Ibom State
Anambra State
Bauchi State
Bayelsa State
Benue State
Borno State
Cross River State
Delta State
Ebonyi State
Edo State
Ekiti State
Enugu State
Abuja (FCT)
Gombe State
Imo State
Jigawa State
Kaduna State
Kano State
Katsina State
Kebbi State
Kogi State
Kwara State
Lagos State
Nasarawa State
Niger State
Ogun State
Ondo State
Osun State
Oyo State
Plateau State
Rivers State
Sokoto State
Taraba State
Yobe State
Zamfara State