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Pre-appointment Questionnaire

If you have a pre-booked face appointment at the health centre, you will be asked these questions prior to attending. This will either be done via telephone with one of our admin team or a clinician, or upon arrival for your appointment. 

Completing this questionnaire online will help to avoid any delay when you attend.

We would like to thank our patients for remaining patient with us. These procedures have been put in place to make it a safer environment for all our patients and staff. 

Pre-appointment Screening Questionnaire
Enter Email
Confirm Email
Please use format day/month/year e.g. 12/05/1979

Pre-appointment Questions

Do you or any member of your household/family have a confirmed diagnosis of COVID-19 diagnosed in the last 14 days?
Do you or any member of your household/family have suspected COVID-19 and are waiting for a COVID-19 test result?

If you have travelled recently please check the Government Red List.

Have you travelled internationally in the last 10 days to a country that is on the Government red list?
Have you had contact with someone with a confirmed diagnosis of COVID-19, or been in isolation with a suspected case in the last 10 days?
Do you have any of the following symptoms:
Have you been had a laboratory test with a confirmed respiratory virus/infection such as Influenza in the last 14 days?
Do you have any new or worsening respiratory symptoms not already mentioned which suggest you may have a respiratory virus?
Have you been had a laboratory test with a confirmed respiratory virus/infection such as Influenza in the last 14 days?

Privacy Policy

This form collects your name, date of birth, email, other personal information and medical details. This is to confirm you are registered with the practice, to allow the practice team to contact you and also to update your medical records held by the practice and our partners in the NHS. Please read our Privacy Policy to discover how we protect and manage your submitted data.