Have you or someone in your household got any of the below symptoms? *

A high temperature (fever or chills)

A continuous cough

A shortness of breath or difficulty in breathing

A loss of , or change in, your normal sense of taste and smell

None of the above

Have you or someone in your household been confirmed Covid-19 positive in the last 10 days? *

Yes

No

Have you been advised that you have been in close contact with someone who is Covid-19 positive in the last 10 days? *

Yes

No

Have you been advised to self isolate or have returned from quarantined countries in the last 10 days? *

Yes

No

Covid-19 Consent *

I understand that there is a risk of transmission of Covid-19 as a result of attending the appointment. I accept the proposed treatment offered at Lavender on the Hill (Marylebone) 21 Beaumont Mews W1G 6EN.