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Winter Virus Health Declaration
How are you feeling today?
Full Name
Phone
Do you or any member of your household currently have:
High Temperature
New, continuous cough
Loss or change to your sense of smell or taste
Do you or any member of your household currently have any newly identified symptoms:
Runny Nose
Sore Throat
Headache
Sneezing
Have you been advised to self-isolate either from track and trace or a recent trip abroad?
Yes
No
Are you consider to be in the extremely vulnerable group?
Yes
No
Have you had the COVID vaccine or a booster in the last 48 hours? If yes we must delay treatment until 48hours has passed.
Yes
No
Are you currently taking medication for COVID-19?
Yes
No
Have you been diagnosed with Long-Covid?
Yes
No
The information I have given in this form is honest, accurate and correct to the best of my knowledge. I have had the opportunity to ask all the questions about its content, and all of my questions have been answered to my satisfaction. I appreciate that although all reasonable steps to reduce risk of infections have been taken, including screening potential Covid-19 cases and undertaking increased hygiene and distancing protocols there may still be a risk of infection from face to face treatment. I knowingly and willing consent for Face to Face appointment to take place.
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