Client health check questionnaire

We are doing all we can to protect our clients and staff while the coronavirus outbreak is still ongoing.

As part of this, we are asking all clients who have made an appointment with us to check if they should be self-isolating.

If you should be in self-isolation, please cancel your appointment. We will reschedule it for you. No cancellation charges will be made.

Otherwise, please fill in and send the form below to declare you are fit to attend.

    Read the following and tick the checkbox only if you agree

    • I am not waiting for the result of a test for coronavirus
    • I have not tested positive for coronavirus
    • I do not have any symptoms of coronavirus (COVID 19). The main symptoms of coronavirus are:
      • High temperature – this means you feel hot to touch on your chest or back (you do not need to measure your temperature).
      • New, continuous cough – this means coughing a lot for more than an hour, or three or more coughing episodes in 24 hours (if you usually have a cough, it may be worse than usual).
      • Loss or change to your sense of smell or taste – this means you’ve noticed you cannot smell or taste anything, or things smell or taste different to normal.
      Most people with coronavirus have at least one of these symptoms.
    • I do not live with someone who is waiting for a coronavirus test result
    • I do not live with someone who has tested positive for coronavirus
    • I do not live with someone who has symptoms of coronavirus (COVID 19) (see above)

    Please visit the NHS website for detailed information about how long you need to self-isolate for.


    We take your privacy seriously and the information we collect about you will be held confidentially and in compliance with GDPR (data protection laws). Your personal information will be stored securely within our IT system or in a locked filing cabinet and can only be seen by members of our team.


    We require the consent of a parent, carer or guardian for us to collect personal information relating to a child under the age of 16. If this applies to you, please fill in the following:

    I am aged 16 or overI am the above named parent/guardian and consent on behalf of the named child

    Please confirm that the above settings are correct before submitting this form.