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?

High temperature?

New, continuous cough?

A loss or alteration to taste or smell?

Have you or any member of your household/family had a confirmed diagnosis of COVID-19 in the last 10 days?

Are you or any member of your household/family waiting for a COVID-19/SARS-CoV-2 PCR test result?

Have you travelled internationally in the last 10 days to a country that is on the government red list?

Have you or any member of your household/family been advised to isolate by any NHS organisation in the last 10 days?

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

Terms & Conditions

I consent to my personal data being collected and stored as per the privacy policy

Treatments

Contact Information

01684 574 131

Somers Road | Malvern | WR14 1JB

Opening Times

Monday – Thursday: 9.00am – 5.00pm
Friday: 8.00am – 4.00pm

COVID-19 Pre Appointment Questionnaire