COVID FORM

The current COVID-19 pandemic

Covid Form

All information provided on the following form will form part of your patient records and not be dilvluged to any third party without your permission.

Has your Medical History or Medication changed since your last visit? *

If 'YES' please provide details

Have you experienced any odd or flu like symptoms over the last two weeks? *

Have you had, or been tested positive, for Covid 19? *

Have you been in contact with anyone who might have had Covid 19? *

Have you been advised, or consider yourself to be in an at risk group? *

Are you Diabetic, have breathing difficulties, or lung disease? *

Do you have any immune deficiency or are you taking steroids? *

Have you had cancer and received chemo or radiotherapy? *

If the answer to any of the above questions is 'YES' please provide details

Find us

W & K Pope Opticians
The Oast Business Centre, 62 Bell Rd, Office 4C, Sittingbourne ME10 4HE

Call us on: +44 (0)1795 470 507

W & K Pope Opticians
83 High St, Sheerness ME12 1TX

Call us on: +44 (0)1795 585 200