COVID-19 Screening & Consent Form

Covid-19 Screening & Consent

Please complete and submit within 48 hours of all clinic appointments

First Name

Last Name

TESTING & VACCINATION

Have you ever been tested for COVID-19 (antigen or antibody)?

Have you had the COVID-19 vaccine?

SYMPTOMS & EXPOSURE

Are you experiencing any of the following symptoms or had possible exposure to Covid-19?

Fever
Persistant cough or having breathing difficulties
Loss of taste or smell
Have you been in contact with anyone with either Covid-19, or having Covid-19 symptoms, in the past 14 days?
Has anyone in your household been in contact with anyone with either Covid-19, or Covid-19 symptoms, in the past 14 days?

If any of the above, advice is to self-isolate or get a test according to government advice, and call 119 for further advice)

ARE YOU CONSIDERED 'HIGH RISK'?

If you are considered a high-risk client, it may not be possible to see you at this time but feel free to discuss this with me. You may need to get clearance from your GP first. This is the current list of ‘high risk’ conditions:

You have been asked to shield by the NHS
older male
have a high body mass index (BMI) over 39
have a health condition such as diabetes, heart or lung disease, etc
are from a Black, Asian or minority ethnic (BAME) background

If you answer YES to any of the above, please contact me to discuss or explain your particular situation.

OTHER QUESIONS:

Have you recently been hospitalised (in the last 4 weeks)?
In the last 14 days, have you traveled abroad or to an area in the UK that has a higher level of risk than our current local level?
Have you developed any new conditions since last visit? eg. pregnancy, long Covid
Allergic to specific cleaning products?

DECLARATION

I solemnly and sincerely declare that the information I have provided is true and correct and I make this solemn declaration conscientiously believing the same to be true. If any person should suffer as a result of the information being found to be untrue and false, then I am aware I can be prosecuted for making a false declaration.
If either I or someone I have been in contact with tests positive for Covid-19 or have been contacted by NHS Test & Trace I will inform you.

Print Full Name

Date

I declare that the info I’ve provided is accurate & complete, and that my name and mobile number on file can be given to NHS Track & Trace if requested.

By submitting this form, you agree to the collection of data in this way.

Thanks for submitting!