COVID-19 Client Declaration

Covid-19 Health Declaration

Our priority at this time is to keep both clients and therapists as safe as possible.

In order to achieve this, we have taken measures in line with the Coronavirus act of 25th March 2020 and are duty-bound to ask you the following set of questions. We assure you that the information you give remains confidential unless legally bound to release it and we thank you for your support.

* If you experience any symptoms mentioned in the checkbox below, however mild, please do not attend your appointment and contact us as soon as you can to change your booking and use the NHS online coronavirus service to check your symptoms and request a test. Please follow the NHS guidance given to you and the guidelines for contact tracing and self-isolation.

NHS online coronavirus service: https://111.nhs.uk/covid-19

First Name

Last Name

Phone

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

I am not experiencing the symptoms: fever, cough, sore throat ,difficultybreathing, headaches,chest pain, joint or muscle pain, loss of tast and/or smell, severe lethargy.

I haven’t had Covid -19 in the last 30days or been in close contact with a Covid-19 patient in the last 14 days

Signature

Date

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

Thanks for submitting!