FACE TO FACE CONTENT:

1

NAME* This field is required.

First Name

Last Name

2

Email* This field is required.

example@example.com

3

Phone Number* This field is required.

Area Code

Phone Number

4

Do you currently have any Covid-19 symptoms? A high temperature, a new or continuous cough, change or loss of taste & smell?* This field is required.

YESNO

5

Have you experienced any cold or flu like symptoms in the last 14 days?* This field is required.

YESNO

6

Have you, or anyone you have come into contact with, tested positive for COVID-19 within the last 14 days?* This field is required.

YESNO

7

Have you returned from a country OUTSIDE of the UK common travel area in the last 14 days? * This field is required.A list of countries in the common travel area can be found here: https://www.gov.uk/government/publications/common-travel-area-guidance

YESNO

8

Are you or your household currently self isolating?* This field is required.Self-isolation is when you stay at home because you have or might have coronavirus (COVID-19).

YESNO

9

Have you received a Covid-19 vaccination within the last 14 days?

YESNO

10

Have you tested positive for Covid-19 within the last 30 days?

YESNO

11

Signature* This field is required.Please sign to confirm.

Clear