COVID-19

PRE-APPOINTMENT WELLNESS

Please complete and submit the following form the day before you visit us.

Name

Phone number

Have you experienced ANY of the following symptoms within the last 14 days?

Temperature or feeling feverish

New cough

Sore throat

Shortness of breath

Flu-llike symptoms such as fatique, headache

Nausea or diarrhoea

Chills or shivering

Muscle pains or rash

Loss of taste OR smell

Have you been diagnosed or suspected of having Covid-19?

No

Yes

If yes please give date or approximate date

Initials

Today's Date

I declare that the info I’ve provided is accurate & complete

Thanks for submitting!

07791 983895

First Floor 1, Victoria Rd, Stoke-on-Trent ST4 2HE, UK