COVID-19 Name* First Last Email Q1: Have you tested positive for COVID -19 in the last 7 days?* Yes No Q2: Are you waiting for a COVID-19 test or the results?* Yes No Q3: Do you have any of the following symptoms: New, continuous cough – high temperature or fever – loss of, or change in, sense of smell or taste?* Yes No Q4: Do you live with someone who has either tested positive for COVID-19 or had symptoms of COVID-19 in the last 14 days?* Yes No Q5: Have you been notified by NHS Test and Trace in the last 14 days that you are a contact of a person who has tested positive for COVID-19 and you do not live with that person?* Yes No Consent COVID-19** please tick to confirm the information is correctSignature*Signature Date DD slash MM slash YYYY PhoneThis field is for validation purposes and should be left unchanged.
