Please complete and submit this form no later than 24 hours before your appointment. Please don’t hsitate to contact me if you have any questions or problems. Please enable JavaScript in your browser to complete this form.Name *FirstLastDate of your appointment *Q1. Have you ever been tested for COVID-19? *YesNoQ2. Have your ever tested positive for COVID-19? *YesNoQ3. If yes, were you hospitalised?YesNoN/AQ4. Are you currently taking medication for COVID-19?YesNoIf you answered yes to Q3 or Q4, please seek consent from your GP or Consultant before your appointmentQ5. Does anyone in your household have COVID-19, or symptoms of COVID-19? *YesNoQ6. Have you or any of your household been contacted by the NHS Test and Trace Team? *YesNoIf you answered yes, your appointment can only take place once the period of self-isolation has been completedQ7. Do you currently have any of the symptoms of COVID-19?A high temperature A new, continuous cough for more than an hour, or 3 or more coughing episodes in 24 hoursLoss or change to your sense of smell or tastePlease defer your appointment if you are waiting for a COVID-19 test result, have recently tested positive for COVID-19. If you currently have symptoms of COVID-19 but have not yet used the online NHS 111 Coronovirus COVID-19 service, please do so. If you have any other new or unusual smptoms please call me on 07985 265905 before your appointment.Q8. Are you considered to be in the High-Risk Group that was shielding? *YesNoNameSubmit Share this:Click to print (Opens in new window)