HomeCovid-19 Screening Hearing Test Triage FormCovid-19 Screening Hearing Test Triage Formcovid-19 hearing screening test online triage formCovid-19 Screening Test Triage Form Questions before a hearing screening test in the age of CoronavirusCOVID-19 Hearing Screening Test Triage FormPLEASE CAREFULLY READ THE FOLLOWING IMPORTANT INFORMATION On 1st June 2020, The British Society of Audiology, The British Academy of Audiology, and The British Society of Hearing Aid Audiologists, with input from ENT UK and The Infection Prevention Society, issued updated guidance on the safe provision of Audiology services, including ear wax removal, in the current context of CoVid-19. In compliance with "Audiology and otology guidance during Covid-19" issued by the above professional bodies, we must triage all patients, including existing ones, before booking their hearing screening test appointment. In order to protect everyone's safety, please read and answer the following questions carefully and truthfully. Failure to do so may put your health and that of our practitioners and other patients at risk. IMPORTANT: YOU WILL NEED TO BRING A MOBILE TELEPHONE WITH YOU WHEN YOU ATTEND YOUR APPOINTMENT. THIS FORM IS MOST EASILY FILLED IN ON A SMART PHONE OR TABLETIn order to prevent you and another patient crossing paths, we will ask you to wait outside, away from the clinic entrance, while observing 2 metres social distancing from other people. This is easiest to achieve if you travel by car and wait in your car. If you have to come by public transport, for your own safety please try to observe 2 metres social distancing from other people as best as you can throughout your journey. We will call you on your mobile telephone when we are ready to see you, and will meet you at the door with a mask for you to put on. As space is limited in our clinic rooms, we regrettably cannot accommodate any extra people, so you (or the patient if you are booking for someone else) will need to be sufficiently mobile to be able to get in and out of the room on your own.Do You Understand The Introduction?*I have carefully read and understand the above introduction. I will bring a mobile telephone with me when I attend the appointment, and will wait outside until I am called.NoYesWhat Clinic Would You Like To Attend?*If you don't know the clinic, then enter the town or postcode where you are looking to get ear wax removal.Your Ear Drum Is...*We are only able to offer hearing test services to people with an ear drum which is not perforated. Please confirm that you do not have a perforated ear drum (a hole in your ear drum).It is very important that you answer this question correctly, as if we find during the procedure that you have a perforated ear drum, we will have to deep clean our equipment before it can be used again. You will be charged an additional £100.Is your ear drum perforated?Please Choose...PerforatedNot PerforatedDo You have Coronavirus?*Do you or anyone in your household have Coronavirus? Also known as CoVid-19 or SARS-CoV-2Please choose...YesNoDo You Have A New, Continuous Cough?*Do you have a new, continuous cough?Please choose...YesNoDo You Have A High Temperature?*Do you have a high temperature (37.8 degrees C or over)? If you do not have a thermometer, does your back or chest feel hot to the touch?Please choose...YesNoDo You Have A Recent Loss Of, Or Change To, Your Sense Of Smell Or Taste?*A loss of, or change to, your sense of smell or taste is now considered a possible early indicator of a CoVid-19 infection.Please choose...YesNoPeople in your household...*Does anyone in your household have a new, continuous cough, a high temperature, or a recent loss of or change to their sense of taste or smell?Please choose...DO have a new, continuous cough, a high temperature, or a loss of or change to their sense of tasteDO NOT have a new, continuous cough, a high temperature, or a loss of or change to their sense of tasteTerms Of Booking - Appointment Fees*Our fees are for the appointment and cover our time and professional services. 36 hours notice must be given for cancellation or rebooking. Do you accept these terms?Please choose...YesNoTerms of Booking - Coronavirus Symptoms* IMPORTANT It is important that you have answered the above answers about Coronavirus, Cough, Temperature and Household correctly to the best of your knowledge. If you have active Coronavirus symptoms during your appointment, we will regrettably have to ask you to leave immediately and either self-isolate or seek medical attention. For the safety of our other patients, we will then have to evacuate the room for one hour, cancel the next patient's appointment, and deep clean the room. You will also be charged an additional £250.We hope you understand the necessity for these stringent measures, as they are there to protect you and our other patients. Do you accept these terms?Please choose...YESNOName*Please confirm your name First Last Email* Consent*COVID-19 You confirm that the answers you have given are correct and give your consent for us to store and process them as required to provide our service to you. I agree for the answers I have given to be stored and processed as necessary for the service to be provided, and confirm these answers to be correctSignature* After you click "Submit", you will go on to the next step. DO NOT click "BOOK NOW (GO TO TRIAGE FORM)" or you will be brought back here. At the very top of the booking page is a blue area with a box for you to enter your postcode. After entering your postcode, either hit enter or click "Find Appointments", and in about 5 seconds the available appointments will be displayed for you to choose.CAPTCHACommentsThis field is for validation purposes and should be left unchanged.