Patient's name: -
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example@example.com
Mobile Number
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Date of Birth
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Have you been vaccinated for COVID19?
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Yes
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First dose only
Two doses
Have you had a booster jab?
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Yes
No
Please take a lateral flow test within 48 hours of your appointment
In the last two weeks have you or anyone in your immediate family had any of the common symptoms of COVID19 such as a persistent dry cough, headache, fever, diarrhoea, or a loss of smell or taste?
*
Yes
No
Did you test positive to COVID19 either by Lateral Flow or PCR tests?
*
Yes
No
Please take a lateral flow test within 48 hours of your appointment
Have you been in close contact with anyone who has tested positive to COVID19 in the last 14 days?
*
Yes
No
Please take a lateral flow test within 48 hours of your appointment
Have you tested negative to either a Lateral Flow or PCR test within 48 hours of your appointment?
*
Yes
No
Have you or anyone you have been in close contact with returned from a red list country in the last 14 days.
*
Yes
No
Please take a lateral flow test within 48 hours of your appointment
Are you a key worker?
*
Yes
No
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