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Client Declaration - For Follow-Up Appointment
Please complete the follow-up declaration form, by answering all the required questions or select (if/where appropriate), and submitting to me beforehand. Thank you!
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* Indicates required question
Email
*
Your email
Full name
*
Your answer
Are you registered on the Test & Trace app?
*
Choose
Yes
No
Have you had a Covid-19 vaccination?
*
Choose
Yes
No
Have you had a positive Covid-19 test in the past 14 days? (Either lateral flow or NHS PCR)
*
Choose
No
Yes
To your knowledge, have you been in contact with anyone with either Covid-19, or having Covid-19 symptoms, in the past 14 days?
*
Choose
No
Yes
Are you experiencing any Covid-19 symptoms?
*
Choose
No
Yes
Have you travelled out of the UK in the past 14 days?
*
Choose
No
Yes
Should anyone I have been in direct contact with over the past 14 days tests positive for Covid-19 I will inform you.
Signed
I declare that the information I have provided is true and correct to the best of my knowledge and belief.
Date
*
MM
/
DD
/
YYYY
Please accept
*
I understand and agree.
Required
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