Name *

First Name

Last Name

Date of Service *

MM

DD

YYYY

In the last 14 days, have you experienced a cough? *

Yes

No

In the last 14 days, have you experienced shortness of breath? *

Yes

No

In the last 14 days, have you had a temperature of 37.7°C or above? *

Yes

No

In the last 14 days, have you experienced a loss or change in your sense of smell or taste? *

Yes

No

In the last 14 days, have you been contacted by the government track & trace system? *

Yes

No

In the last 14 days, have you been abroad OR been in contact with anyone that has been abroad? *

Yes

No

Do you live with someone who has either tested positive for COVID-19 or had symptoms in the last 14 days? *

Yes

No

Have you been classified by your doctor as 'high risk' or clinically vulnerable? *

Yes

No

Agreement

I have read, understood and completed this form truthfully to my knowledge.

I knowingly and willingly consent to having services carried out by the House of Bendy team during the Covid-19 pandemic.