COVID-19 screening questions

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We treat the health and safety of our patients, staff and the community as our highest priority. By answering the below questions honestly you are helping us achieve this goal.

All information submitted through this form is used for COVID-19 screening purposes only. Your information will not be shared with anyone.

First Name *

Surname *

Phone number *

How many dependents (eg children) are you filling out this form for?

Which surgery are you attending? *

Are you (or any of your dependents) currently experiencing any cold or flu-like symptoms? For example cough, runny nose, fever, loss of taste/smell? *

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