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COVID-19 Questionnaire

Prior to your upcoming appointment, please can you complete the following form to comply with our new COVID-19 procedures.

Do you have any of the following symptoms?

  • a High Temperature - this means that you feel hot to touch on your chest or back (you do not need to measure your temperature)
  • a new, continuous cough - this means coughing a lot more than an hour, or 3 or more coughing episodes in 24 hours (if you usually have a cough, it may be worse than usual)
  • a loss or change to your sense of smell or taste - this means you've noticed you cannot smell or taste anything, or things smell or taste different to normal