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.

If you answered yes to Q3 or Q4, please seek consent from your GP or Consultant before your appointment
If you answered yes, your appointment can only take place once the period of self-isolation has been completed
Please 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.