01273 563902|info@placefarmhouse.co.uk| Facebook
01273 563902|info@placefarmhouse.co.uk| Facebook

COVID-19 Visitor Screening Questionnaire

To safeguard our home and the elderly residents that live here, we would request that you complete the screening questions below. We would ask that you answer the questions honestly, with the best interests of the vulnerable elderly people at heart.

1. Have you been feeling unwell recently?:
 Yes    No
2. In the past 2/3 days have you shown any symptoms for COVID-19 (cough, high temperature, loss of taste and smell)?
 Yes    No
3. Do you suffer from (& receive treatment for) chest and breathing problems? E.g Asthma, bronchitis, allergies
 Yes    No
4. Are you aware of recent contact (in the last 14 days) with anyone with COVID-19 symptoms or someone with confirmed COVID-19. This may have been confirmed by NHS Test and Trace?
 Yes    No
5. Have you returned from a country outside the United Kingdom in the last 14 days?
 Yes    No
6. Have you had the first or second dose of the vaccine?
 Yes    No

COVID-19 Lateral Flow Test Consent

I am aware that in order to enter the home and visit my relative or carry out essential maintenance, the home's policy is that a COVID-19 Lateral Flow Test (LFT) is carried out on you and the results reported to the home via info@placefarmhose.co.uk

I give my consent for staff to do testing as appropriate and report the results to the home, in the hope this may help to minimise the risk.

Do you consent to the Lateral Flow Test and data reporting?  Yes    No