Please complete and submite the following form if asked to do so by you health care professional. This form, along with other tests and x-rays you may have had, will help the long COVID clinic support your assessment and any recommendations for treatment.

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Personal Details

Please provide your details to help us find your record. If you are filling this in on behalf of someone else, please enter their details.

Please double check you've entered the correct email address
 
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Long COVID Questionnaire

Please complete this questionnaire only if requested to do so by your GP practice

E.g. could you work from home, do fewer hours, or do different tasks at work?
 
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Confirmation

Please confirm your details are correct

Date of Birth:

Gender:

Phone Number:

Privacy Consent

This form collects personal and medical information about you. We use this information to allow the practice team to contact you. Please read our Privacy Policy to discover how we protect and manage your submitted data.

 
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