Online Hayfever Consent Form

First name *

Surname *

Address *

Postcode *

Date of Birth *

Contact Number

Email

Have you or anyone in your household had COVID-19? *

Do you have or have you had a high temperature in the last 7 days? *

Please select the treatment you require an appointment for *

If you treatment is not in the list, please call the clinic

Kenalog 40mg/1ml