Covid-19 Screening Form
Please complete ALL fields, and return at least 3 days prior to your appointment
Patient's name: -
*
First Name
Last Name
Email
*
example@example.com
Mobile Number
*
Date of Birth
*
/
Day
/
Month
Year
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1 - Do you have any of the following symptoms:-
High temperature or fever?
*
Yes
No
New continuous cough?
*
Yes
No
A loss or alteration to taste or smell?
*
Yes
No
2 - Have you or any member of your household/ family had a confirmed diagnosis of Covid-19 in the last 10 days?
*
Yes
No
3 - Are you or any member of your household/ family waiting for a COVID-19/ SARS-CoV-2 PCR test result?
*
Yes
No
4 - Have you travelled internationally in the last 10 days to a country that is on the government red list?
*
Yes
No
5 - Have you or any member of your household/ family been advised to isolate by any NHS organisation in the last 10 days?
*
Yes
No
Please provide as much information as possible ie dates, etc
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Signature
*
Please draw signature with mouse or finger
Date
-
Day
-
Month
Year
Date
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