Clone of Child Chest Clinic Preclinic Questionnaire

Child Chest Clinic Preclinic Questionnaire - Dr Chin Nwokoro

To be completed by carer prior to or after booking an outpatient appointment with Dr Chin
1. Patient Name
2. Date of Birth

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
3. Patient Address

Street Address

Street Address Line 2
CityCountyPostcode
4. NHS Number if known
5. Parent 1 Name
6. Parent 2 Name
7. Parent Email address
Please enter the best email address for correspondence.
8. Phone number
9. GP name
If no specific individual GP use the GP Practice name.
10. GP practice name and address
You can find your practice details here: https://www.nhs.uk/service-search/find-a-gp or here: https://www.odsdatasearchandexport.nhs.uk/
11. Has your appointment been confirmed
12. Please state your confirmed appointment location
13. Please state your confirmed appointment date

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
Hour MinutesAM/PM Option
14. Please state your preferred clinic location
15. Please state your preferred clinic date (Thursdays 10-4 only) and approximate preferred time

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
Hour MinutesAM/PM Option

Payment Details
16. How will you pay?
17. I understand that self-pay fees are £275 for a first video or face to face appointment, £200 for a follow-up, and that lung function testing will incur additional fees (https://www.childchestclinic.com/terms-and-conditions).
18. Insurer Name
19. Other Insurer
20. Insurer Membership Number
21. Insurer Preauthorisation Number

COVID/Viral Safety
36. Do you or other family member have any COVID-19 or other viral symptoms?
Symptoms may include new persistent cough, fever above 38C, muscle aches, persistent headache, blocked or runny nose, sneezing, sore throat, facial pain, diarrhoea or vomiting, or new onset persistent tiredness or fatiguability. Children or family members with these symptoms should reschedule or confirm appropriateness of attending with the clinic team at secretary@childchestclinic.com.

Conditions of Attendance

Please contact the clinic directly if there is a problem with any of these (elstreepatientadmin@hcahealthcare.co.uk, 02035536765 OR hatfield.reservations@phoenixhospitalgroup.com, 01707443333), and copy your email to secretary@childchestclinic.com (07753882808).
42. I understand that I should arrive around 10 minutes before my appointment to complete paperwork and be weighed/measured.
43. I understand that I MUST inform the clinic (secretary@childchestclinic.com) if I or a family member has or develops any symptoms of COVID-19 or other febrile illness, and that my appointment *may* be rescheduled.
44. I understand that my child's appointment is not confirmed until I have prepaid the self pay consultation fee.
Click "Submit" to send the form and request written confirmation of the appointment. Self pay patients will receive a prepayment link and will need to make payment before the appointment is confirmed.
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Child Chest Clinic Preclinic Questionnaire - Dr Chin Nwokoro