Covid-19 Health Declaration Form

Name *

First Name

Last Name

Have you tested positive for Covid-19 within the last 14 days? *

Yes

No

Have you experienced any of the following symptoms within the last 14 days? *

High temperature

Shortness of breath or difficulty breathing

New persistent cough

Loss of taste and/or smell

Muscle aches

I have not had any of the above

Have you been in contact* with anyone who has tested positive for covid-19 or are displaying any of the symptoms listed above within the last 14 days? *

* Contact with another person includes, but is not limited to any of the following: a) Living in the same household, regardless of whether 2-metre social distancing has been adhered to, or PPE was worn by either person. b) Face-to-face contact within the home address for any length of time, with persons who do not live in the household, regardless of whether 2-metre social distancing has been adhered to, or PPE was worn by either person c) Being within 2 metres for any length of time, with persons outside of the home address, regardless of whether PPE was worn by either person.

Yes

No

Are you currently self-isolating? *

Yes

No

Have you been advised to shield? *

Yes

No

To the best of your knowledge, have you answered all the above questions truthfully and honestly? *

Yes

No

Do you agree to notify Victoria Winfield immediately, should you or anyone you have come into contact with within 14 days of your booking, develop symptoms or is diagnosed with Covid-19? *

Yes

No

Do you agree to notify Victoria Winfield immediately should there be any changes to your answers after completion of this form and prior to your booking? *

Victoria can be contacted on info@victoriawinfieldbridal.co.uk

Yes

No