Kingdom Carpets COVID-19 questionnaire and consent form

COVID-19 Health Questionnaire & Booking Form

It is imperative that you answer this questionnaire accurately and agree to do so. Inaccurate answers put yourself, other customers and our staff at increased risk of exposure to the COVID-19 virus.
The main symptoms of coronavirus (COVID-19) are:
- a high temperature – this means you feel hot to touch on your chest or back (you do not need to measure your temperature)
- a new, continuous cough – this means coughing a lot for more than an hour, or 3 or more coughing episodes in 24 hours (if you usually have a cough, it may be worse than usual)
- a loss or change to your sense of smell or taste – this means you've noticed you cannot smell or taste anything, or things smell or taste different to normal.
Have you or has anyone you live with experienced any of the above symptoms in the last 14 days?*

YesNo
Are you currently experiencing any of the above symptoms?*

YesNo
Have you tested positive or been in contact with anyone who has tested positive for COVID-19 in the past 14 days?*

YesNo
Are you awaiting the results of a COVID-19 test ?*

YesNo
Have you travelled abroad in the last 14 days?*

YesNo
If you have answered yes to any of the above questions or you are unsure, you must cancel your appointment immediately & seek medical advice.
Name*

First NameLast Name
Postcode*

Postcode
Phone Number*
Email*
example@example.com
I understand that Kingdom Carpets is required to collect and retain customer's information, for a limited time period, for the purposes of the COVID-19 contact tracing scheme. I understand that my information will be provided by Kingdom Carpets to the COVID-19 contact tracing scheme if required to do so.*

Yes. By checking this box I understand & accept this statement
To prevent the spread of COVID-19 and to help protect myself, other customers and shop staff, I understand I will have to follow Kingdom Carpets guidelines at all times.*

Yes. By checking this box I understand & accept this statement
I understand that COVID-19 is a highly contagious virus and understand that every possible precaution has been taken by Kingdom Carpets. I understand that if I arrange a fitting or measure via Kingdom Carpets, it is my duty to inform them of any changes to the above information and must cancel my scheduled fitting / measure should I be presenting symptoms, have been asked to self isolate or if I or anyone in my household are awaiting test results or have tested positive to COVID-19.*

Yes. By checking this box I understand & accept this statement
I confirm I have been truthful and accurate with my answers*

Yes. By checking this box I understand & accept this statement
Signature*

Clear
This information will be held confidentially and in compliance with GDPR and in line with government and insurance requirements.
Appointment*
Should be Empty:

COVID-19 Health Questionnaire & Booking Form