Covid-19 Wellness Check

info@bravomedicalaesthetics.co.uk

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Bravo Medical Aesthetics

Please fill out the following form within 24 hours prior to your appointment to ensure that you are fit to attend. Failure to submit the form within this timeframe may delay your appointment.

First Name

Email Address

Last Name

Date of Birth

Have you or any of your family members / immediate / close contacts currently sick or experiencing ANY of the following symptoms within the last 14 days?

Temperature or feeling feverish

New cough

Sore throat

Shortness of breath

Flu-like symptoms such as factique or headache

Nausea or diarrhoea

Chills or shivering

Muscle pains or rash

Loss of taste or smell

None of the above

Have you or any of your family members or immediate / close contacts recently travelled internationally, travelled within the UK, or attended a public event in the last 15 days?

No

Yes

If you answered yes to any question above, or have been diagnosed or suspected with having Covid-19, please elaborate and provide details of any Covid-19 swab or antibody test result in the box below:

Initials

Today's Date

I declare that the info I’ve provided is accurate & complete

Thanks for submitting!

info@bravomedicalaesthetics.co.uk

Clinic locations: Peterborough, Newport Pagnell, Chatteris and Ely

+447488328935