COVID-19 Questionnaire

To ensure the health and safety of all our staff and all other customers of Reface Scotland, we ask all customers to complete this questionnaire prior to your home visit.

Please Enter Your Details:

Your First Name* (required)

Your Surname* (required)

Your Email* (required)

Your Phone Number* (required)

Your Postcode* (required)

COVID-19:

Do you, or anyone in your household, have a fever, a new persistent cough, loss of taste or smell or any other symptoms of COVID-19?* (required)

YesNo

Have you tested positive for COVID-19 in the last 7 days or are you awaiting a test or a result of a test?* (required)

YesNo

Have you been advised to self isolate as part of the COVID -19 contact tracing program or from any other source?* (required)

YesNo

Do you live with someone who has either tested positive for COVID-19 or had symptoms of COVID-19 in the last 14 days?* (required)

YesNo