Consultation & Consent Document – Specific COVID-19 Screening

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* 1. Name

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* 2. Email Address

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* 3. SYMPTOMS - Are you experiencing any of the following?

Tick this box if you are not experiencing any of the symptoms below

Fever

Cough

Sore throat or runny nose

Chills or headache

Painful swallowing

Muscle & joint ache (not related to exercise or posture)

Fatigue or exhaustion

Loss of taste or smell

Shortness of breath or difficulty lying down due to chest issues

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* 4. Contact and Testing

Tick if you have been tested for Covid-19 in the last 10 days: please let us know the result in the box below.

Tick if you have been in contact with anyone with Covid-19 symptoms in the last 10 days.

N/A

Date of Covid-19 Test

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* 5. If you have had Covid are you still experiencing symptoms (long Covid)?

Yes - add details below

N/A

When did you test positive and is the self-isolation period over?

Are you still experiencing symptoms: if so, what?

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* 6. Do you have any of the following health issues?

I do not have any of the conditions listed below

Tick if you have high blood pressure or other heart condition

Tick if you have Diabetes Type 1 or 2

Tick if you have cancer

Tick if you have a lung condition

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* 7. Tick any of the boxes that apply to you.

None of the below statements refer to me

I'm a NHS front line worker

I'm a carer – home or care home

I'm shielding a vulnerable adult

I'm pregnant – please add how many weeks in the comment box below

I'm over 70

I'm allergic to latex gloves or cleaning products – please specify in the comment box below

Additional comments

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* 8. Our Governing Body's guidelines advise the use of gloves. However, it is not mandatory and the scientific evidence demonstrates that thorough hand washing is more effective in infection control for diseases such a Covid-19. Therefore if you would prefer us not to use gloves please tick this box.

I would prefer a treatment without gloves

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* 9. I declare that the information I have provided is true and correct.

If either I or someone I have been in contact with tests positive for Covid-19 in the next 10 days I will inform you.

Tick to agree with the statement above.

Consultation & Consent Document – Specific COVID-19 Screening

Question Title

* 1. Name

Question Title

* 2. Email Address

Question Title

* 3. SYMPTOMS - Are you experiencing any of the following?

Question Title

* 4. Contact and Testing

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* 5. If you have had Covid are you still experiencing symptoms (long Covid)?

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* 6. Do you have any of the following health issues?

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* 7. Tick any of the boxes that apply to you.

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* 9. I declare that the information I have provided is true and correct.If either I or someone I have been in contact with tests positive for Covid-19 in the next 10 days I will inform you.

* 9. I declare that the information I have provided is true and correct.

If either I or someone I have been in contact with tests positive for Covid-19 in the next 10 days I will inform you.