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01243 214 776

info@chilgroveclinic.co.uk

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?

Thanks for submitting!

To get the best out of all the treatments that we offer, a consultation is required. This is a valuable one to one meeting focused on you, and will provide you with qualified and experienced advice. A booking fee of £50 is payable before you attend, and this will be deducted from any treatments or products that you invest in following your consultation.

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ALL CONSULTATIONS ARE BY APPOINTMENT ONLY

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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