PRE-CONSULTATION QUESTIONNAIRE

PRE-CONSULTATION QUESTIONNAIRE

Could you please complete our COVID-19 screening questions. We are doing this to ensure the safety of all our clients and staff members. Thank you.

If we do not receive your completed form within 12 hours of your scheduled appointment, we may be unable to proceed with your consultation. Thank you for your co-operation.

Full Name *

Are you currently experiencing, or have you had any of the following symptoms in the last 14 days? Fever >38 degrees, difficulty breathing, coughing or a sore throat? * *

YesNo

Details if applicable

Have you had contact with anyone with confirmed OR suspected COVID19 in the last 14 days *

YesNo

If I develop any of the above symptoms over the next 24/48 hours I will contact the office to advise them in advance of my consultation. * *

I agree

If you have arrived in Ireland from a country on the Red list in the last 14 days, in order to comply with the 14 day quarantine rule, you will need to contact us to change your appointment to an Online Consultation as soon as you can. Please click to let us know you agree *

I agree