MEDICAL QUESTIONNAIRE

Form
Client Name *

First Name Last Name
Address *

Street Address

Street Address Line 2

City County
Phone Number *

+44 Phone Number
Email *
example@example.com
Have you or have you been in contact with anyone who has been diagnosed with COVID-19 in the last 14 days? *

YES NO
Have you experienced any cold or flu-like symptoms in the last 14 days? *

YES NO
Have you had either one or both shots of the COVID-19 vaccine? *

YES NO
If you answered yes to the above question, please provide the date you had your last COVID-19 vaccination

Day Month Year
Date
Consent

I understand that I am opting for an elective medical treatment. I understand the novel Coronavirus, COVID-19, has been declared a worldwide pandemic by the WHO and that COVID-19 is extremely contagious and is believed to be spread by person-to-person contact; and, as a result, social distancing is recommended. This is not entirely possible with my proposed treatment, however, I am satisfied that safety measures are in place to minimise risk as much as possible, and patient contact will be kept to an absolute minimum in line with medical need. I also understand that although measures are in place, there is an inherent risk of becoming infected with COVID-19 by virtue of proceeding with treatment. I hearby acknowledge and assume the risk of becoming infected with COVID-19 through this elective medical treatment and I give my express permission to proceed. I confirm that if I develop any symptoms following my treatment, or a known contact of mine develops symptoms, I will immediately inform the clinic to enable appropriate measures to be put in place and contact tracing to commence.
Signature

Clear
Date

Month Day Year
Date
Should be Empty:

Form

Consent