Covid-19 Self Assessment Form

We ask all patients to complete or update a confidential medical questionnaire via our online portal before attending the practice.  If you have difficulties with the portal or you are accompanying a family member, we would ask you to complete the form below, within 24 hours of the appointment.

Your responses will of course be treated in confidence. If you do answer yes to any of the questions we would ask that you do not attend the practice and follow Government advice regarding self isolation. Please phone or email us when you are able to and we will re-schedule your appointment.

Having filled in the assessment form, should you be taken ill with COVID-19 symptoms on the day of your appointment, please do not attend. Please let us know of your change in condition by phoning the practice on 01442 865646.

COVID-19 Self Assessment Form

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  • This field is for validation purposes and should be left unchanged.