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. 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.Name* First Last Email Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Phone*Where did you find out about us?*Friend or RelativeInternet SearchFacebook/Social MediaGP Leaflet/ReferralHospital LeafletReturning CustomerOtherPlease 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 CAPTCHACommentsThis field is for validation purposes and should be left unchanged.
