Covid-19 Health Declaration

How are you feeling today?

First Name

Last Name

Only tick the box if your answer is YES to the questions

Have you had a fever in the last 10 days? (feeling hot to touch on your chest and back)

Do you now, or have you recently had, a persistent dry cough? (coughing a lot for more than an hour, 3 or more coughing episodes in 24 hours or worsening of a pre-existing cough)

Have you lost sensations of taste and smell?

Have you been in contact with anyone in the last 14 days who has been diagnosed with Covid-19 or has coronavirus-type symptoms?

Have you been told to stay home, self-isolate or self-quarantine?

Do you or anyone that you live with fall in to the ‘clinically vulnerable’or ‘clinically extremely vulnerable’ categories as defined below?

Your Signature

Date

I declare that the info I’ve provided is accurate & complete

Consent for treatment: I understand that, because my treatment may involve touch and close physical proximity over an extended period of time, there may be an elevated risk of disease transmission, including Covid-19. I give my consent to receive treatment from the practitioner.

Thanks for submitting!

During lockdown we have been advised to treat only urgent and high needs patients. Do you consider yourself to be in that category. (Please get in touch if you are not sure)