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Have you had / suffered from or experienced any of the below Covid-19 symptoms within the last 14 days? Have you had / suffered from or experienced any of the below Covid-19 symptoms within the last 14 days? Fever Persistent Cough No

Have you been abroad in the last 14 days? Have you been abroad in the last 14 days? Yes No

Have you been diagnosed with Covid-19 in the last 8 weeks? Have you been diagnosed with Covid-19 in the last 8 weeks? Yes No

Do you fall in the governments high risk category? Do you fall in the governments high risk category? Are over the age of 70 Have underlying health issues Pregnant No

If you are having a chemical service have you had a skin test since your last appointment? If you are having a chemical service have you had a skin test since your last appointment? Yes No

Are you allergic to latex gloves? Are you allergic to latex gloves? Yes No

Please contact us regarding your appointment - 07419 328 404 Please contact us regarding your appointment - 07419 328 404 OK

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