All About You - COVID-19 Screening

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Please take the time to fill in our COVID-19 screening questions. We provide a close contact service and need you to help us maintain a COVID free environment. We may also be required to pass on some of your information such as name and contact details to support the NHS test and trace if needed. Your details will not be shared for any other reason. We will keep your screening questionnaire secure for 21 days and after that time your form will be deleted from our database. If you do NOT want your contacts details shared for the purpose of the NHS Test and Trace we will not pass your details on, please tell us you wish to opt out.
Please ensure that this form is completed prior to attending your appointment.

Email *

Full Name *

Phone Number *

Address *

Have you experienced any of the following symptoms in the last two weeks? *

Fever

New, persistent cough

Loss of taste or smell

Shortness of breath

Extreme tiredness

No to All of the above

Required

Have you been tested for COVID-19 *

YES

If you tested POSITIVE please include the date of your test

YYYY

Have you received the COVID-19 Vaccination in the last 2 weeks? *

YES

If "YES" to the last question, please confirm the date you received your most recent vaccination.

YYYY

Have you come into contact with anyone who has suspected or tested positive for COVID-19 in the last 14 days? *

YES

NOT SURE

General Health

Let us know if you are shielding or fall into a high risk category. *

YES

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