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Contact Us
Home
About Us
Our Official Charity Partner
Meet the Team
Clients
Testimonials
Acquired or Traumatic Brain Injury
Spinal Injury
Other Medical Conditions
Live Vacancies
Register CV
Candidates
Apply online
Supporting Our Official Charity Partner
Subject Access Requests
Refer a Friend Scheme
Care Packages for Brain and Spinal injury
Contact Us
Covid 19 declaration
Covid 19
Name
*
First
Last
Date
*
Date Format: DD slash MM slash YYYY
Current Vaccination status
*
1st Dose Received
2nd Dose Received
Booster Dose Received
Awaiting appointment and I want the vaccine
I will not be getting vaccinated
I am still undecided and would like to get more information from one of your nurses.
Please tick the box that best describes your vaccination status
Evidence of Vaccination
Accepted file types: jpg, gif, png, pdf.
Please take a photo of your vaccination card with the date your vaccine was administered clearly showing and upload it here
I agree that if I or anyone in my household develop any symptoms of COVID 19:
*
I will inform Libertatem Healthcare Group via email as soon as possible
I will not put anyone at risk and will refrain from attending work if I am specifically instructed to self quarantine
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