Long Covid

Long COVID form NEL


Information
Information

You have been sent this form because you have ongoing COVID symptoms. It is quite lengthy because the hospital need as much information as possible to make sure you get the type of help you need. You may wish to get somebody to help complete it with you, or come back to it several times to complete it.

Identification Questions

In order to identify patients correctly, we would like you to answer the following questions.

Identification Questions

In order to identify patients correctly, we would like you to answer the following questions.

If you have an NHS login, use it now and save time on filling in some details.



Are you the patient? *

Additional information

Please could you give us your own details first and then provide the patients details

Now can you enter the patients details:

Gender *
Preferred contact: *
Preferred contact:

Please note that the sick note will be sent via email.

Page last reviewed: 24 September 2021