Name *

First Name

Last Name

Question 1 *

Have you or anyone you reside with or care for suffered from any of the below recognised symptoms of, or tested positive for coronavirus within the last 7 days? - A high temperature - A new, continuous cough - Loss or change to your sense of smell or taste

Yes

No

Question 2 *

Have you have been in contact with a person suffering with any of the above recognised symptoms, or who has tested positive for coronavirus within the last 7 days?

Yes

No