Covid Health Questionnaire
Thank you for taking the time to answer these questions. Please confirm that prior to my treatment:
Name
*
First Name
Last Name
Phone Number
*
Email
*
example@example.com
1. I have not been diagnosed with or have cared for someone diagnosed with COVID-19 in the past 10 days.
*
I can confirm this.
2. I do not have a cough, fever, chills, shortness of breath or loss of taste or smell.
*
I can confirm this.
3. I am not showing symptoms of COVID-19 or come into close contact with anyone exhibiting symptoms.
*
I can confirm this.
6. If I begin to show symptoms of COVID-19 within the next two weeks, I will contact you immediately.
*
Yes, I agree.
7. Would you like to subscribe to our newsletter? They'll be few and far between I promise.
Yes please
No thanks
I already subscribe
Signature (Please use your finger as you would a pen)
Date
-
Day
-
Month
Year
Date
Submit
Should be Empty: