COVID-19 Form | enhance

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Covid-19 Health Declaration

How are you feeling today?

First Name

Last Name

Email

My body temperature is lower than 98.6°F/ 37.5°C

I am not experiencing the symptoms: fever, cough, sore throat

I haven’t been in close contact with a Covid-19 patient in the last 14 days

Initials

Date

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

Thanks for submitting!

Clinic Opening Times

Mon: 5pm-9pm

Tues: 5pm-9pm

Wed: 5pm-9pm

Thurs: 5pm-9pm

Fri: 5pm-7pm

Sat: Closed

Sun: Upon Request

7 Market Street

Lichfield

WS13 6JX

Name *

Email *

Phone

Message

Thanks! Message sent.

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