Covid-19 Screening Form
Please complete ALL fields, and return at least 3 days prior to your appointment
Patient's name: -
*
First Name
Last Name
Email
*
example@example.com
Mobile Number
*
Date of Birth
*
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Day
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Month
Year
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In the last month have you or anyone in your immediate family had any of the common symptoms of COVID19 such as a persistent dry cough, fever, or a loss of smell or taste?
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Yes
No
Do you think you may have already had COVID19 more than one month ago?
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Yes
No
Have you tested POSITIVE to either a nasopharyngeal swab or antibody test?
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Yes
No
Have you tested NEGATIVE to either a nasopharyngeal swab or antibody test in the last 14 days?
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Yes
No
Have you been in close contact with anyone who has tested positive to COVID19 in the last month?
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Yes
No
Do you think you might have COVID19 at the moment?
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Yes
No
Have you or anyone you have been in close contact with returned from abroad in the last 14 days
*
Yes
No
Are you a key worker?
*
Yes
No
Additional information:-
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Signature
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