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.

Do you consider yourself an urgent or high risk needs patient. ( if unsure , please get in touch)

Thanks for submitting!