Covid-19 Questionnaire

COVID-19 IMPORTANT INFORMATION ABOUT YOUR BOOKING, PLEASE READ!

1. No patient can attend who has had Covid-19 symptoms or anyone within their home group for the past 14 days.

2. Face masks must be worn and are available to anyone who needs them. Please ask.

3. Hand sanitiser is available in my studio for you to use as you enter.

4. If you develop any Covid-19 symptoms in the days following your appointment, please do notify me so that we can track and trace accordingly.

I have a Garden Studio where I practice, so entrance is through the garage. This studio has all facilities. I will leave the main drive clear so you can park there and the garage door will be left open. Please wait in your car until I come and fetch you.

I will be wearing a face mask during your treatment and the studio will be well ventilated and hand sanitiser will be available for use.

I change all linen on my couch regularly and wash them on a hot wash.

Please let me know if you have any questions.

Your Name: *

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Last

Your E-Mail Address: *

Contact Phone Number: *

Address *

Address Line 1

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City

State / Province / Region

Postal Code

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Do you, or anyone in your household have a fever, new persistent cough, loss of taste of smell or any other symptoms of Covid-19? *

• Yes
• No

Have you tested positive for Covid-19 in the last 7 days or are you awaiting a test or a result of a test? *

• Yes
• No

Have you been advised to self isolate as part of the Covid-19 contact tracing programme or from any other source? *

• Yes
• No

Do you live with someone who has either tested positive for Covid-19 or had symptoms of Covid-19 in the last 10 days? *

• Yes
• No

Have you received a Covid-19 Vaccine? *

• Yes
• No

If you answered Yes to the previous question, how many doses of the vaccine have you had?

• One
• Two
• Three

If you answered No, Why? *

GDPR Agreement *

• I consent to having this website store my submitted information so they can respond to my inquiry.

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