COVID-19 Patient consent (Subsequent visits to CRGW since COVID-19 lockdown). Patient has previously completed the ‘1st visit since lockdown form’.

You will need to complete an online form before any attendance at CRGW while COVID-19 risks persist.

The first online form you will compete is the ‘1st visit questionnaire’.

For every subsequent visit to CRGW you will complete the ‘Repeat visit questionnaire’.

COVID Consent: To complete for subsequent visits to CRGW following lockdown (1st visit since lockdown form previously completed)

COVID Consent: Subsequent visits

Form to be completed prior to every visit to CRGW while still during the COVID-19 infection.

I am aware that I do not complete this form any earlier than 24 hours before my appointment*
Please complete this form no more than 24 hours prior to all subsequent visits having already attended CRGW for the first time since COVID-19 lockdown.
Today's date*
DD slash MM slash YYYY

(dd/mm/yyyy)
Which clinic(s) do you wish to be seen at?*
Name*
Date of birth*
DD slash MM slash YYYY

(dd/mm/yyyy)
Telephone Number*
Email*
Enter Email Confirm Email
Partners Name (if applicable)
Partners date of birth (if applicable)
DD slash MM slash YYYY

(dd/mm/yyyy)
Partners telephone number (if applicable)
Partners email (if applicable)
Enter Email Confirm Email
Do you have any of the following symptoms?*
A high temperature (fever) A new continuous cough A loss of smell or taste (anosmia)
Have you (or your partner if applicable) returned from any countries outside of the UK within the last 14 days*
Have you returned from any countries outside of the UK within the last 14 days?
Have you (or your partner if applicable) had close contact with or cared for someone diagnosed with COVID-19 within the last 14 days?*
Have you (or your partner if applicable) been in close contact with anyone who has traveled within the last 14 days to any country listed as a COVID-19 infectious area?*
Have you (or your partner if applicable) experienced any cold or flu-like symptoms in the last 14 days (to include fever, cough, sore throat, respiratory illness, difficulty breathing)*
Are you (or your partner if applicable) shielding from COVID-19 or live with people who are shielding?*
*Shielding is when people vulnerable to COVID-19 self isolate
Electronic signature (Patient)*

My electronic signature below confirms I have read and understand the COVID-19 specific information above.
Electronic signature (Partner - if applicable)

My electronic signature below confirms I have read and understand the COVID-19 specific information above.
FORM COMPLETED BUT FURTHER CLARIFICATION REQUIRED*

PLEASE INITIAL THE BOX ABOVE. Clarification is required prior to your appointment at CRGW by our staff due to your answers provided. Please submit your form by clicking below.
Email
This field is for validation purposes and should be left unchanged.