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Pre Appointment Questions

Do you or anyone in your household have any of the following symptoms?

Fever/Flu symptoms Yes No

Fatigue Yes No

Altered or Loss of Taste/Smell Yes No

Cough Yes No

Shortness of breath Yes No

 

Have you or anyone in your household been in contact with anyone in the last 14 days who has had a confirmed case of Covid 19? Yes No

Have you or anyone in your household been advised to self-isolate in the last 14 days? Yes No

 

Since you last visit to us has there been any changes to you general health or any medications? Yes No

If yes please give further details:

Is there anything else you feel we need to know before you attend for your appointment? Yes No

If yes please give further details:

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