Covid 19 Screening

Name *

First Name Last Name

Email *

example@example.com

Phone Number *

Area Code Phone Number

Have you tested positive for COVID19 at any stage? *

Yes No

Have you been in contact with anyone with a confirmed Covid19 diagnosis in the last 2 weeks? *

Yes No

Have you had any of the following Covid19 symptoms in the last 14 days? *

Raised temperature/fever New persistent cough Loss of taste Loss of smell None of the above

Are you shielding or is anyone in your household shielding due to having any of the 'vulnerable conditions' *

Yes No

Are you above the age of 70 years old? *

Yes No

I certify that this information is true to the best of my knowledge and I agree to notify the clinic if I develop any of the above symptoms between now and my appointment.

Signature *

Clear

Date *

Date

We advise that you consider a video consultation rather than a face to face appointment unless there is a clinical need to have hands on physiotherapy. We reserve the right to refuse a face to face appointment if it is deemed unnecessary or unsafe. This is in line with the recommendations from our regulatory body 'The Chartered Society of Physiotherapy'.

We have done everything we can to reduce the risk of the clinician and patients contracting Covid-19. However, if you come for face to face treatment, please be aware that there is no way that we can eliminate the risk of you contracting Covid-19.

When coming for your appointment, please be mindful of the following:

- please come to the clinic alone

- please wait outside until you are called in

- please avoid using the toilet unless absolutely necessary

- please use the hand sanitiser provided on arrival

- please come with a face mask if you have one, if not you will be provided with one

- please pay by BACS or contactless payment

Thank you.