Face to Face Appointments Face to Face Appointment Form Please fill out this form if you'd like a face to face appointment with us at your chosen branch. Name* First Last Email Address* Street Address City ZIP / Postal Code Phone*Where did you find out about us?*Friend or RelativeInternet SearchFacebook/Social MediaGP Leaflet/ReferralHospital LeafletReturning CustomerAll Ears Wales (Catryn)OtherPlease tick all that apply** I or someone in my household has contracted Coronavirus (Covid-19) within the last 14 days I or someone in my household has had a new, continuous cough within the last 14 days I or someone in my household has had a loss of taste / smell in last 14 days I or someone in my household has had a high temperature (37.8C or over) within the last 14 days I or someone in my household has been feeling unwell in the last 14 days I or someone in my household has been advised to shield by a health professional / authority I or someone in my household has been in contact with a Covid-19 infected person within the last 14 days I as the person needing wax removal have a perforated ear drum that is not healed In the last 14 days no-one in our household has had any Covid-19 symptoms or is aware of being in contact with Covid-19 In the last 14 days no-one in our household has had a sore throat, runny nose or been suffering from headaches ? Consent I agree to collecting info on this form (please tick to confirm consent)If you'd like to know more about how we look after your data please see our privacy policy here.CAPTCHAPhoneThis field is for validation purposes and should be left unchanged. Δ
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