Pre-appointment Covid-19 Questionnaire

Appointment Date and Time *

Does anybody attending have any accessibility requirements we need to plan for ahead of your visit? *

Yes
No

Please provide relevant details:

GDPR Agreement *

I / We consent to having this website store my submitted information for the purposes listed below:

By submitting this form, you consent to Wallace Quinn sharing your contact details if asked by any relevant authority or their representatives for assistance in any ‘track and trace’ programmes. Wallace Quinn will keep the information provided in this form for up to one month after your appointment and will then destroy it. The information provided in this form will not be used for any other purpose.

Name of first person attending appointment *

First

Last

Home address (inc postcode) *

telephone and email details: *

Name of second person attending appointment (if applicable)

First

Last

Person 2 - Home address (inc postcode)

if same as person 1, write 'same'

Person 2 - telephone and email details:

Do you, or anybody in your household, currently have any of the symptoms of Coronavirus – (1) a high temperature or fever (2) a new and persistent cough or (3) A loss of, or change in taste or smell *

First Person - Yes
First person - No
Second Person - Yes
Second Person - No

Have you, or anybody in your household, had a test for Covid-19 and are awaiting results? *

First Person - Yes
First Person - No
Second Person - Yes
Second Person - No

By attending your appointment, would you be breaking any rules around shielding or self-isolation? *

First Person - Yes
Second Person - No
First Person - Yes
Second Person - No

You MUST complete this form ahead of your visit.

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