Regalus services Ltd

Have you/anyone you have been in contact with/ or in your household

had covid 19 symptoms? Yes or No.

Have you had a fever in the last 7 days? Yes or No

Do you or have you had a persistent cough. Coughing for more than an
hour/or for 24 hours?

Have you lost taste/smell/ feeling fatigue/shortness of breath?

Have you travelled outside the UK in the past 14 days?

Have you had an organ transplant/Chemotherapy/Cancer/Imunno

suppressant medication/ Sickle cell/ high dosage steroids? Yes or No

Do you understand that a Health Care Professitional takes every

precaution to follow stringent care to provide a safe environment using
PPE etc. However I can not guarantee that your appointment will be risk
free. From exposure to Covid 19. And other Seasonal ailments. Yes or No

If I Maxine Brown get symptoms of Covid 19 within 48 hours of being in

contact with yourself. I am obliged by the law to give your name and
telephone number, date and time to the track and trace service.

Patient consents signature: