Covid screening and consent form

Please complete this form within 24 hours of your appointment

First Name

Email Address

Last Name

Date of Birth

I confirm that I have not had any of the following symptoms in the last 14 days: fever, shortness of breath, loss of sense of taste or smell, dry continuous cough.

Yes

I confirm that to the best of my knowledge, I have not been in close contact with anyone with confirmed COVID-19 or anyone with COVID-19 symptoms in the last 14 days.

Yes

I confirm that I understand that my physiotherapy appointment may involve close contact within 2m, therefore my therapist is required to wear appropriate PPE (gloves, apron, mask and visor), and that I am required to wear a mask during my appointment and sanitise my hands before and after leaving the clinic. I therefore consent to a face to face appointment.

Yes

Do you have any questions?

Initials

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

Thanks for submitting!

Covid screening and consent form

THE CLINIC

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