Pre -Appointment COVID-19 Checklist {In Confidence}
In these uncertain times Hartleys are striving to ensure that we observe our Government’s guidance designed to protect wherever possible the virus being transmitted between our customers and our staff. We would greatly appreciate your assistance in doing this by completing this checklist. It will only be used in connection with any appointments in your home or on our premises, and will be destroyed when no longer needed.
PRE-APPOINTMENT CHECKS: NAME ………………………………….. Ref No (office) ………………………………..
TRAVEL-Have you been out of the country in the last month (tick) Yes… No…
If yes, please provide the date of your return ………………………………….. .
If yes Where did you travel to? …………………………………………………………………..
Do/Did you have to self-isolate on your return? Yes….No…
HEALTH -Have you experienced any of the following symptoms in the last 14 days (please tick any or all that apply and give further details in the space below)?
Fever of 37.8C or higher… Loss of taste or smell…
A new continuous cough, where you cough for more than an hour or have three or more coughing episodes in 24 hours? …
NONE OF THE ABOVE …
Further Details ………………………………………………………………………………………………………………….
……………………………………………………………………………………………………………………………………………………..
CONTACT
Have you been in contact with anyone known to have Covid-19 in the last 2 weeks? Yes… No…
If you answered yes to the above please contact reception to rearrange your appointment.
Have you had to self-isolate with Covid-19 symptoms in the last month? Yes… No…
If answering yes to either, please give further details below:
………………………………………………………………………………………………………………………………………………….
………………………………………………………………………………………………………………………………………………….
IF THERE ARE ANY CHANGES TO YOUR ANSWERS ABOVE BETWEEN MAKING THE APPOINTMENT AND OUR HOME DESIGN VISIT PLEASE CONTACT THE OFFICE ON 01756 700471.
Date Completed ………………………………………………….. .
Thank you for your co-operation.
