The information provided will be attached to your consultation form and will be safely stored.
Your Full Name (required)
Your Email (required)
Do you currently have COVID-19 or any symptoms of COVID-19? (required) YesNo
Please defer your treatment if you: are waiting for a COVID-19 test result; have recently tested positive for COVID-19, or have a high temperature, new continuous cough, or a loss or change to your sense of taste or smell. If you currently have symptoms of COVID-19 but have not yet used the NHS 111 online coronavirus service, please do so. If you have any other new or unusual symptoms, please discuss these with me before the appointment.
Have you had COVID-19? (required) YesNo
If you have had COVID-19, please seek consent from your GP or consultant before treatment.
Does anyone in your household or support bubble have COVID-19 or symptoms of COVID-19? (required) YesNo
Have you been in close contact with anyone else in the past 14 days who has symptoms of COVID-19, or been contacted by the NHS Test and Trace service and told to self-isolate? YesNo
If yes to either question, please defer attending your appointment until it is safe to do so.
Are you classed as an extremely vulnerable person (high risk)? (required) YesNo
If you are classed as clinically extremely vulnerable and require shielding, you will have received a letter from the NHS explaining this. Defer treatments until the government indicates that it is safe for you to leave home or have visitors providing non-essential care.
Are you classed as a vulnerable person (moderate risk)? (required) YesNo
Unlike people at high risk, those who are classed as clinically vulnerable will not have received a letter from the NHS. If you are unsure if you are clinically vulnerable, please refer to the NHS website at www.nhs.uk. If you meet the definition of someone who is clinically vulnerable, please discuss this further with me and seek consent from your GP, midwife or consultant before having a treatment.
Please check your temperature before going to your treatment. If it is higher than usual, or if you have any other symptoms, please contact me to defer the treatment. Please ensure that you follow all new procedures explained to you, prior to treatment. A link is in the text message sent to you.
Accept the conditions 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 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.