Covid-19 DeclarationPlease enable JavaScript in your browser to complete this form.Name *FirstLastEmail *Date of Appointment *Do you, or anyone in your household, currently have Covid-19? *Click to select...YesNoDo you, or anyone in your household, have a high temperature (over 37.8 degrees) *Click to select...YesNoDo you, or anyone in your household, have a persistent dry cough? *Click to select...YesNoHave you, or anyone in your household, experienced a loss of taste or smell? *Click to select...YesNoHave you been in contact with anyone who has Covid-19 int last 14 days? *Click to select...YesNoDo you understand the safety measures put in place to protect you? *Click to select...YesNoConfirmation *I confirm that the information I have provided is accurate and I am happy to proceed with my appointmentDate *NameSubmit