COVID-19 Pre-Attendance Triage Assessment

Please complete the following questionnaire no later than 6pm on the day before your appointment. If this is not done it may be necessary to reschedule your appointment. By submitting the form below, I confirm I have read and understood the following COVID-19 disclaimer:

COVID-19 Disclaimer

Current Government rules in addition to a pre-medical COVID-19 risk assessment may mean either yourself or the AME may be unable at short notice to attend/undertake your medical.  

On booking your medical, this risk is accepted and no liabilities or financial penalties will be borne by either party.

Do you or any other member of your household/family have a confirmed diagnosis of COVID-19?: *
Are you or any member of your household/family currently unwell?: *
Is anyone in your household waiting for a COVID-19 test result?: *
Have you travelled internationally in the last 14 days? [Exclude travel related to your work as an airline pilot or member of cabin crew] : *
Have you had contact with someone outside your household with a confirmed diagnosis of COVID-19?: *
Have you been required to self-isolate in the last 14 days?: *
Do you currently have a high temperature or fever?: *
Do you currently have a new or continuous cough?: *
Do you currently have a loss or alteration to taste or smell?: *
Do you feel unwell?: *

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Phone me now on 07910 126111 to book your medical or just fill in the form below and I'll contact you !

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