COVID-19 form

Before each appointment I need to complete a coronavirus check with you. Please can you complete the below and submit the form before visiting the clinic. This needs to be completed for each appointment until further notice.

I will be completing a lateral flow test twice a week and if I suspect any symptoms of COVID-19, or if I think there is a possible exposure risk, I will contact you.

I look forward to seeing you at your appointment!

Name*

Date*

I have completed a COVID-19 test in the last 3 days*

If yes, please advise if positive or negative:

I have received a coronavirus vaccination within 7 days of my appointment*

If yes, please give date:

In the last 14 days, have you been in contact with someone who has been diagnosed with or suspected of having Covid-19 or been contacted by NHS Test & Trace team and advised to self isolate?*

Do you have any of the following?

A high temperature, a new, continuous cough (coughing a lot for more than an hour, or 3 or more coughing episodes), or change to your sense of smell or taste?*

COVID-19 form

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