Covid-19 Questionnaire

We can all help to keep Wales safe.
We can all help to keep Wales safe.

Covid-19 has not gone away.  My team and I continue to take measures to keep us all safe, including wearing a mask, sanitising surfaces, ensuring ventilation, and reducing the time spent indoors.

Any information you can share ahead of your appointment will allow more time to review.

Please also take a few minutes to complete the questionnaire below no more than 24 hours before your appointment.  If you need to reschedule your visit, my team will be happy to look at alternative dates and times.

Best wishes,

Gerald Jones MP
Merthyr Tydfil & Rhymney

Covid-19 Questionnaire

Name(Required)
Address(Required)
Do you have any recent onset / new symptoms of Covid-19. Cold, flu or other respiratory symptoms such as: high temperature; new, continuous cough; a loss or alteration to taste and/ or smell; sore throat; runny nose and/ or sneezing; shortness of breath?(Required)
Have you or any member of your household or family had a confirmed diagnosis of Covid-19 in the last 10 days or travelled internationally?(Required)
Are you or any member of your household or family waiting for a PCR test result?(Required)
Have you or any member of your household or family been advised to isolate by any NHS organisation in the last 10 days?(Required)
I confirm that this information are accurate to the best of my knowledge.(Required)
Date(Required)
Privacy agreement(Required)
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