It is important to us that this form is completed in full, failure to complete the form will result in us not being able to see you for your appointment. We kindly ask that this form is completed prior to your appointment date.
Date of Birth
Do you have a new persistent cough or a fever, temperature over 37.8?
Have you been in contact with anyone in the last 14 days that has/had the COVID19 virus? (including any family members)
Have you or your family members been told to self isolate in the last 14 days?
In the last 14 days, have you had any other symptoms related to COVID19?
If yes, please specify below
Please insert N/A if applicable
According to government guidelines, would you consider yourself to be either vulnerable, medically compromised or shielding at home during lockdown (including any family members)?
If you selected yes, please give details below:
If you selected no, please insert N/A in the box above
Do you have any changes to your current Medical History?
If yes, pleases specify below
Insert N/A if no changes to your Medical History
Should be Empty:
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