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Covid 19 Information
Client Name
*
Contact Email
*
Address
Street Address
Address Line 2
Date
*
Date Format: MM slash DD slash YYYY
Does anyone at the property being visited:
Have a high temperature?
Yes
No
Have a new persistent cough?
Yes
No
Have an altered sense of taste/smell?
Yes
No
Is anyone at the property undergoing self-isolation/quarantine?
Yes
No
Is there anyone at the property who is considered vulnerable to, or requires shielding from, COVID-19 as a result of:
Aged over 70
Yes
No
Underlying health condition
Yes
No
Pregnancy
Yes
No
Have you implemented current government advice https://www.gov.uk/coronavirus on your premises?
Yes
No
Do you have facilities for handwashing?
Yes
No
By submitting this form, I confirm that I have read and agree to the Pinkham Equine advice on visits and will inform the practice if any of there are any changes in the above questions.
*
Yes
