COVID Visit 3
VISITING BOOKING AND DISCLAIMER FORM
 
To ensure that it is completely SAFE to visit Forget me not Care home during the coronavirus crisis and WINTER NOROVIRUS we would ask that you read and consent the following disclaimer, which amounts to a “Visitor’s code”.
 
I consent to COVID-19 testing on the day of the visit date and understand that a POSITIVE will result in the visit being cancelled with immediate effect. (Date and time of visit to be confirmed via e-mail)
 
I confirm I will be responsible for logging my test result on the Government website and consent to the results being forwarded to e-mail address info@forgetmenotburnham.co.uk to enable efficient communication of result.

I confirm that at the time of my planned visit I have not been told to self-isolate on the grounds that I:
• have travelled to a high-risk area which on return has required that I should immediately self-isolate and I am still within that period of self-isolation.
• have travelled to an area, where on return I was required to self-isolate if I developed any Covid-19 symptoms and I have developed those symptoms.
• have been in contact with someone who has had symptoms of Covid-19 and who was a known risk (e.g. because of the foregoing reasons) or has been confirmed as having Covid-19.

I confirm that I will only visit if I am feeling well (covid 19 related or not) *
I confirm I have received the FIRST Covid 19 vaccination *
I confirm I have received the SECOND Covid 19 vaccination *
I confirm I have received the BOOSTER Covid 19 vaccination *
I confirm I have received the FLU vaccination *
I consent to my temperature being taken before entering the home. Should my temperature be above 37.2c I understand that entry will be declined without notice. *
I confirm that I understand that contact is restricted to holding hands only and I must refrain from kissing and/or cuddling. *
I confirm that I will wear supplied Forget me not PPE throughout the visit. *
I confirm that I understand that I must remain in the visiting room allocated during the visit. *
I confirm that I understand I will not be able to use any toilet facilities and staff will be unable to offer any refreshments. *
I confirm that any gifts must be given to staff before the visit, to enable the items to be quarantined for safety for 72 hours. *
* Please note we will send an acknowledgement to this email address, please keep an eye on your junk and spam folders in case it is mis-directed
Preferred day and times (please give at least three choices) *