CORONAVIRUS (COVID-19) PRE-SCREENING QUESTIONNAIRE – MUST BE COMPLETED PRIOR TO REGISTRATION

□ Are you, or anyone within your household or support bubble, displaying symptoms of Coronavirus such as a high temperature, a new
continuous cough, or a loss or change to your sense of smell or taste, or have you been notified via NHS Test and Trace that you have
been in contact with anyone displaying symptoms/infected with COVID-19? Yes No
If yes, you must leave branch immediately and you must self-isolate in line with the Government guidelines for 10-14 days.
□ Have you travelled outside of the UK in the last 14 days? Yes No
□ If so, where did you travel to and when did you return to the UK? ……………………………………………………….......
If you have returned from any of the countries which are exempt from ‘all but essential travel’ in the last 14 days, you must self-isolate
in line with the Government guidelines for 10-14 days.
□ Do you have any plans to travel outside the UK in the near future? Yes No
□ If yes, where do you plan to travel to and when? …………………………………………………………………………….
If you plan to travel to any of the countries which are exempt from ‘all but essential travel’, you must self-isolate upon your return in
line with the Government guidelines for 10-14 days.

COVID-19 STATEMENT – MUST BE READ TO APPLICANT PRIOR TO REGISTRATION

If at any point between the time of this conversation and your scheduled registration appointment you, or anyone within your household
or support bubble, displays symptoms of Coronavirus such as a high temperature, a new continuous cough, or a loss or change to your
sense of smell or taste, or you are notified via NHS Test and Trace that you have been in contact with anyone displaying
symptoms/infected with COVID-19, you must inform Extra Personnel immediately and must not attend your appointment. You must self-
isolate in line with the Government guidelines for 10-14 days, after which, providing you are no longer exhibiting any symptoms, you
should contact Extra Personnel and your appointment will be rescheduled. Please confirm that you agree to this?

Yes No

COVID-19 statement read to applicant?

Applicant confirmed their understanding and agreed to the rules regarding self-isolation and rescheduling their
registration appointment?

Comments

Consultant Name

Consultant Signature Date

EPC19PS V1 25/09/2020