Consultation form

Your reference number from us (begins with CL)(required)

Your first name

Have you had a recent covid test?(required) Yes

No

If yes, please give type, date & result

Have you experienced any cold or flu-like symptoms in the last 10 days (including fever, cough, sore throat, respiratory illness, difficulty breathing)? Yes

No

If yes, please give details

Please tell us about any other conditions you have or if you are pregnant

Have you had a covid vaccination?(required) No

Yes 1 dose

Yes 2 doses

Yes 2 doses plus booster

Who can we contact in an emergency?

Emergency contact number

Thank you