Home
About
Treatments
Treatments
Book Now
News
Latest News
Covid-19
Contact
Covid-19 Screening Form
Name
*
Telephone Number
*
Email Address
*
Have you previously had a Covid-19 Test?
*
No
Yes - an antigen test for Covid symptoms
Yes - an antibody test for previous infection
If yes, please provide the date of the test
What was a result of this test?
Are you experiencing any of the following symptoms?
Fever
Onset, or worsening cough
Sore throat or runny nose
Chills or headaches
Pain Swallowing
Fatigue or Exhaustion
Loss of taste or smell
To your knowledge, have you been in contact with anyone with Covid-19 symptoms?
*
Yes
No
Have you been hospitalised recently?
Yes
No
If yes, please provide details
Do you have any of the following?
High Blood Pressure or other heart conditions
Diabetes Type I/II
Cancer
Respiratory/Lung Conditions
Are you currently any of the following?
An NHS Key Worker
A Carer - Home or Care home
Shielding a vulnerable adult
Pregnant
Aged over 70
Are you experiencing post Covid-19 circulatory complications (deep vein thrombosis, micro-embolism, stroke symptoms or pulmonary embolism)?
Yes
No
Please provide any additional information we may need to be aware of ahead of your appointment
Declaration
*
I declare that the information I have provided is true and correct and I make this 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.
