• Covid screening and consent

    Please complete before attending your appointment
  •  -

  • Testing

  • Have you had a COVID 19 test?
  • When?
     - -
    2 digit day, 2 digit month, 4 digit year
  • What type of test?
  • Has the isolation period expired?
  • Do you still have symptoms?

  • Symptoms

    Are you experiencing any of the following?
  • Do you have a persistent cough?
  • Do you have a fever (above 37.8 °C)
  • Have you lost or experiencing a reduced sense of taste or smell?
  • Have you been in contact with anyone with COVID 19 symptoms or living in a household with someone who is self isolating due to covid-19 symptoms?

  • If YES to any of the above, please follow Scottish Government guidelines and self isolate and get tested.

  • Current Health Issues

    (Extra precautions with PPE may be required)
  • Have you recently been hospitalised?
  • Do you have high blood pressure or a heart condition?
  • Do you have any form of diabetes?
  • What type of diabetes

  • Do you have cancer?
  • Do you have any respiratory conditions?
  • Are you pregnant?
  • Are over 70?

  • Previously Contracted Covid-19

    (Treatment may not be possible at this stage)
  • Are you experiencing post Covid-19 circulatory complications (Deep vein thrombosis (DVT), Micro-embolism, Stroke symptoms, or Pulmonary embolism)

  • Exposure to Covid-19?

    (Extra precautions with PPE may be required)
  • An NHS frontline worker
  • A carer- home or care home
  • Shielding a vulnerable adult
  • Are allergic to latex gloves or any specific cleaning products?

  • Signed

  • I solemnly and sincerely declare that the information I have provided is true and correct and as I make this solemn declaration conscientiously believing the same to be true. If any person should suffer as a result of the information being found to be untrue and false, then I am aware I can be prosecuted for making a false declaration.

    If either I or someone I have been in contact with tests positive for covid-19 or have been contactacted by NHS Test ant Trace I will inform you.

  • Clear
  • Date
     - -
    2 digit month, 2 digit day, 4 digit year

  • Thank you for filling in this form. Could you also please read the procedures that I must know follow before, during and after appointments and what is required of you- it's not much. Covid Procedures (opens in new tab)

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