All About You - COVID-19 Screening
Please take the time to fill in our COVID-19 screening questions. We provide a close contact service and need you to help us maintain a COVID free environment. We may also be required to pass on some of your information such as name and contact details to support the NHS test and trace if needed. Your details will not be shared for any other reason. We will keep your screening questionnaire secure for 21 days and after that time your form will be deleted from our database. If you do NOT want your contacts details shared for the purpose of the NHS Test and Trace we will not pass your details on, please tell us you wish to opt out.
Please ensure that this form is completed prior to attending your appointment.
Email address *
Full Name *
Phone Number *
Address *
Have you experienced any of the following symptoms in the last two weeks? *
Required
Have you been tested for COVID-19 *
If you tested POSITIVE please include the date of your test
MM
/
DD
/
YYYY
Have you travelled abroad in the last 1 month? *
If "YES" to the last question, which countries did you travel to?
Have you come into contact with anyone who has suspected or tested positive for COVID-19 in the last 14 days? *
General Health
Let us know if you are shielding or fall into a high risk category. *
Next
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy