Triage Health Questionnaire

Before we can admit you to the clinic, and to comply with latest clinical guidance, we must ask you to complete this form.

Are you currently suspected of having COVID-19?
Do you have a fever, or have you had a high temperature in the last 14 days (a fever is a temperature greater than 37.8°c? )
Have you had a cough or any other respiratory signs in the last 14 days?
Have you been vaccinated against Covid-19 in the last 14 days?
Do you suffer from any of the following? Diabetes, cardiovascular disease, including hypertension, chronic lung disease, immunodeficiency, cancer under active treatment?
Are you pregnant?
Are you over 70 years of age?
Have you been living with, or in contact with someone suspected of, or confirmed with COVID-19?

Please note that ALL CONSULTATIONS AND TREATMENTS ARE

STRICTLY BY APPOINTMENT ONLY

All treatments subject to medical checks. Full Terms and Conditions HERE

The Chilgrove Clinic, Chilgrove Business Centre, Chilgrove Park Road,

Chilgrove, West Sussex PO18 9HU

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