COVID 19

Please make sure to fill in this questionnaire 48 hours before each appointment. It is extremely important to answer all questions honestly, this is important for both of our safety.

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Covid-19 Health Declaration

How are you feeling today?

Please answer all questions 48 hours before your appointment.

Please remember if this form is not completed I reserve the right to refuse service to anyone whom I deem not suitable for treatment or for any other reason at my own discretion.

Please remember this to ensure the safety of yourself and others.

First Name

Last Name

Address

Postcode

Phone

Date of Appointment

My body temperature is lower than 98.6°F/ 37.5°C

I am not experiencing symptoms: fever, cough, sore throat, loss of taste or smell

I haven’t been in close contact with a Covid-19 patient in the last 14 days

I haven't travelled outside of the UK in the past 10 days

Initials

Date

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

Thanks for submitting!

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COVID 19

Covid-19 Health Declaration

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